“Sharp 300% Surge: Soaring Incidents of ADHD Medication Errors in U.S. Children”

A recent study has brought to light a remarkable escalation in instances of medication errors related to Attention-deficit/hyperactivity disorder (ADHD) treatment in children. Notably, the majority of these incidents transpired within the confines of households and primarily involved male children aged between 6 and 12 years. The study underscores the pressing need for augmented education and more efficient medication management practices to curb the alarming rise in these errors.

The Critical Need for Education and Enhanced Medication Dispensing Systems

ADHD, a prevalent pediatric neurodevelopmental disorder, has gained recognition as one of the most commonly diagnosed conditions in American children, with approximately 10% of children in the United States receiving an ADHD diagnosis in 2019. Currently, around 5 out of every 100 children in the U.S. are prescribed medication for ADHD.

Escalation in ADHD Medication Errors

In a recently published study appearing in the Pediatrics journal, researchers from the Center for Injury Research and Policy and the Central Ohio Poison Center at Nationwide Children’s Hospital delved into the characteristics and trends associated with out-of-hospital ADHD medication errors in individuals under the age of 20, as reported to U.S. poison centers from the year 2000 to 2021.

According to this study, the annual count of ADHD-related medication errors surged by a staggering 299% during the two-decade period from 2000 to 2021. Over the study duration, a total of 87,691 cases of medication errors involving ADHD drugs as the primary substance were reported to U.S. poison centers among this age group, equating to an average of 3,985 cases annually. In the year 2021 alone, an astonishing 5,235 medication errors were documented, translating to one child experiencing such an error every 100 minutes. Notably, this concerning trend was predominantly driven by male individuals, who accounted for 76% of the medication errors, and children aged between 6 and 12 years, contributing to 67% of these errors. Strikingly, a substantial 93% of these exposures occurred within the confines of homes.

Common Scenarios of Medication Errors

Among the medication errors involving ADHD drugs as the primary substance, three primary scenarios emerged as most common:

1. 54% – “Inadvertently taken/given medication twice”
2. 13% – “Inadvertently taken/given someone else’s medication”
3. 13% – “Wrong medication taken/given”

Natalie Rine, PharmD, co-author of the study and director of the Central Ohio Poison Center at Nationwide Children’s Hospital, noted, “The increase in the reported number of medication errors is consistent with the findings of other studies reporting an increase in the diagnosis of ADHD among U.S. children during the past two decades, which is likely associated with an increase in the use of ADHD medications.”

Health Consequences and Strategies for Prevention

A concerning aspect of these findings is that, in 83% of cases, individuals did not receive treatment in a healthcare facility. However, 2.3% of cases necessitated admission to a healthcare facility, including 0.8% to a critical care unit. Additionally, 4.2% of cases were linked to serious medical consequences, with some children experiencing agitation, tremors, seizures, and alterations in mental status. Notably, children under the age of 6 were twice as likely to experience serious medical consequences and more than three times as likely to be admitted to a healthcare facility compared to their counterparts aged 6 to 19.

In response to these disconcerting findings, Gary Smith, MD, DrPH, senior author of the study and director of the Center for Injury Research and Policy at Nationwide Children’s Hospital, emphasized the need for proactive measures. He stated, “Because ADHD medication errors are preventable, more attention should be given to patient and caregiver education and development of improved child-resistant medication dispensing and tracking systems. Another strategy may be a transition from pill bottles to unit-dose packaging, like blister packs, which may aid in remembering whether a medication has already been taken or given.”

While prevention efforts should certainly focus on the home setting, it is equally crucial to extend attention to schools and other environments where children and adolescents receive medication.

Reference: “Pediatric ADHD Medication Errors Reported to United States Poison Centers, 2000 to 2021” by Mikaela M. DeCoster, BS; Henry A. Spiller, MS, D.ABAT; Jaahnavi Badeti, MPH, BDS; Marcel J. Casavant, MD; Natalie I. Rine, PharmD, BCPS, BCCCP; Nichole L. Michaels, PhD; Motao Zhu, MD, MS, PhD; Gary A. Smith, MD, DrPH, 18 September 2023, PEDIATRICS.
DOI: 10.1542/peds.2023-061942

This study drew its data from the National Poison Data System (NPDS), which is administered by America’s Poison Centers, formerly known as the American Association of Poison Control Centers (AAPCC). Poison centers gather information through the national Poison Help Line (1-800-222-1222), documenting details about the product, exposure route, individuals affected, exposure scenarios, and other pertinent data, which are subsequently reported to the NPDS.

Frequently Asked Questions (FAQs) about ADHD Medication Errors

More about ADHD Medication Errors

• Pediatrics Journal: Access the study “Pediatric ADHD Medication Errors Reported to United States Poison Centers, 2000 to 2021” in the Pediatrics journal.
• Center for Injury Research and Policy: Learn more about the Center for Injury Research and Policy at Nationwide Children’s Hospital.
• ADHD Information: For comprehensive information on Attention-deficit/hyperactivity disorder (ADHD), visit the CDC’s ADHD webpage.
• America’s Poison Centers: Explore resources and information about America’s Poison Centers, where data for the study was obtained.