Medication Mistakes in Pediatric Emergencies: Real Cases and How to Prevent Them

Every year, thousands of children end up in emergency rooms because of a simple mistake: the wrong dose of medicine. Not because parents are careless, but because the system is stacked against them. In pediatric emergencies, medication errors happen more than twice as often as in adults. A 2023 study found that 31% of pediatric medication orders contain some kind of error-compared to just 13% for adults. And in real life, these aren’t just numbers. They’re children who got too much acetaminophen, too little antibiotics, or the wrong liquid formula because the label was confusing.

Why Kids Are at Higher Risk

Adults get pills. Kids get liquids. And liquids are where things go wrong.

Most pediatric doses are calculated by weight-milligrams per kilogram. That means if a child weighs 10 kg, and the dose is 15 mg/kg, you need to multiply 10 by 15 to get 150 mg. Then you have to figure out how many milliliters that equals based on the concentration of the liquid. One bottle might be 160 mg per 5 mL. Another might be 250 mg per 5 mL. Mix them up, and you’ve given a child five times the dose they should have.

Studies show that 60% to 80% of dosing errors at home involve liquid medications. One parent in a 2024 Reddit thread said they gave their 2-year-old 5 mL of children’s Tylenol, thinking it was the same as infant Tylenol. It wasn’t. The infant version is twice as strong. The child ended up in the ER with liver damage.

Even in hospitals, mistakes happen. A 2019 study found 0.78 errors per medication order in pediatric emergency departments. That’s nearly one mistake for every dose given. Why? Time pressure. Verbal orders. Overworked staff. And the fact that many hospitals still don’t have pediatric-specific tools built into their electronic systems.

Common Mistakes and Real Cases

Let’s look at what actually goes wrong.

• Wrong dose (13% of errors): A child with a fever gets 5 mL of liquid acetaminophen instead of 5 mg/kg. If the child weighs 10 kg, the correct dose is 150 mg. But 5 mL of standard children’s acetaminophen (160 mg/5 mL) is 160 mg-close enough, right? Not if the bottle says “infant” and the concentration is 80 mg/0.8 mL. That’s 500 mg in 5 mL. Ten times too much.
• Duplicate dosing (15-25% of cases): Mom gives Tylenol at 8 a.m. Dad gives it again at 11 a.m. because he didn’t know it was already given. Or worse-both give it because they’re using different measuring tools. One uses a cup, the other a syringe. Neither knows the difference between mL and mg.
• Wrong concentration: A parent receives discharge instructions saying “give 5 mL.” They assume all children’s Tylenol is the same. But infant drops and children’s suspension are not interchangeable. One is 80 mg/0.8 mL. The other is 160 mg/5 mL. Give the wrong one, and you overdose.
• Weight misestimation: In 10-31% of errors, the child’s weight is wrong. Parents guess. Nurses estimate. A child who weighs 15 kg gets dosed as if they’re 20 kg. That’s a 33% overdose before the calculation even starts.

One case from a 2019 incident report: a mother gave her 10 kg child 5 mL of liquid acetaminophen, thinking it was the right amount. The bottle was labeled 160 mg/5 mL. She didn’t realize the correct dose was 150 mg total. She gave 160 mg-close, but the real problem was she gave it every 4 hours for 12 hours straight. The child developed acute liver failure. They survived, but barely.

Who’s Most at Risk?

This isn’t just about mistakes. It’s about inequality.

Parents with low health literacy are 2.3 times more likely to make a dosing error. Families who speak limited English have a 45% error rate compared to 28% for English speakers. Children on Medicaid have 27% higher error rates than those with private insurance. Why? Because they’re more likely to get discharge instructions in a language they don’t understand. More likely to use kitchen spoons because they don’t have a dosing syringe. More likely to be rushed out of the ER without time to ask questions.

One study found that Spanish-speaking families had 32% higher dosing error rates-even when given translated instructions. Translation alone isn’t enough. The instructions need to be visual. Simple. Repeated.

What Works: Real Solutions

It’s not hopeless. Some hospitals have turned things around.

Nationwide Children’s Hospital in Ohio cut harmful medication events by 85% in five years. How? They did three things:

1. They made every pediatric dose calculation go through pharmacy verification before it’s given.
2. They built weight-based dosing calculators directly into their electronic records. If a doctor types in “acetaminophen,” the system auto-calculates the dose based on the child’s weight and shows the correct volume in mL.
3. They started using the “teach-back” method: after giving instructions, they ask the parent, “Can you show me how you’ll give this medicine?”

Another program, called MEDS, tested a simple change: instead of handing out a paper sheet with tiny text, they gave parents a card with pictures and one clear instruction: “Give 5 mL every 6 hours.” No numbers. No mg/kg. Just a picture of a syringe and a clock. They also gave every family a dosing syringe. Result? Dosing errors dropped from 64.7% to 49.2%-and stayed down even after the program ended.

Even small changes help. Using a dosing syringe instead of a teaspoon cuts errors by 35-45%. A 2024 JAMA study found that families who used syringes were far less likely to make mistakes than those who used cups or spoons.

What Hospitals Still Get Wrong

Not every hospital has a pediatric specialist on staff. Not every ER has a dosing calculator built into their system. Many community hospitals still rely on paper charts, handwritten orders, and nurses who estimate weights because the scale is broken.

Only 68% of children’s hospitals have pediatric-specific EMR tools. That number drops to under 30% in general emergency departments. That means a child who lives in a rural town and goes to the nearest ER might get a dose calculated the same way as an adult-because the system doesn’t know how to do it differently.

And even when tools exist, they’re not always used. One nurse told a researcher: “I know the system says to double-check, but we’re swamped. I’ve done this a thousand times.” That’s the dangerous mindset. One time is all it takes.

What Parents Can Do Right Now

You don’t need a medical degree to keep your child safe.

• Always ask: “What’s the exact dose in milliliters?” Not “How much?” Not “A teaspoon?” Ask for the number of mL.
• Use the syringe that comes with the medicine. Never use a kitchen spoon. Even a tablespoon isn’t accurate.
• Write it down. Write the dose, the time, and the date on your phone or a piece of paper. Show it to the next caregiver.
• Check the label twice. Is it “infant” or “children’s”? Is it 80 mg/0.8 mL or 160 mg/5 mL? They’re not the same.
• Ask the teach-back question: “Can you show me how you’ll give this?” If you’re unsure, ask the nurse or pharmacist to watch you do it.

One parent in Sydney told me: “I used to think I was being careful. Then I gave my daughter the wrong dose because I didn’t realize the bottle had changed. I cried for days.” She now keeps a photo of the correct syringe fill line on her phone. She shows it to every nurse.

The Bigger Picture

Medication errors in children aren’t about bad parents or lazy doctors. They’re about systems that haven’t caught up to the reality of pediatric care.

Every child deserves a system that works for them-not one that assumes they’re just small adults. That means standardized dosing tools. Clear labeling. Pharmacy checks. And training that doesn’t stop after orientation.

By 2025, the American Academy of Pediatrics plans to roll out standardized metrics to track outpatient medication errors. That’s a start. But until every ER, every pharmacy, every home has the right tools and the right training, children will keep getting hurt by mistakes that should never happen.

The good news? We know what works. We’ve seen it. We’ve measured it. Now we just need to do it everywhere.