“Shocking Study Reveals: Medication Shortage in Canada Causing Dangerous Dosing Errors in Children!”

# Study Finds Increase in Dosing Errors in Children During Canada-wide Medication Shortage

A recent study conducted by Sunnybrook Health Sciences Centre in Toronto has found that dosing errors in children increased during the Canada-wide shortage of paediatric fever and pain medication last year. The study looked at the number of monthly calls to the Ontario Poison Centre (OPC) for unintentional acetaminophen and ibuprofen dosing errors among patients 18 years of age or younger between January 1, 2018, and February 28, 2023.

## The Impact of the Medication Shortage

During the medication shortage, between August and December 2022, there was a 40 to 60 per cent increase in calls to the OPC compared to trends over the prior four years. Margaret Thompson, medical director of the OPC, said the shortage of paediatric analgesia and anti-fever medications led to parents and caregivers using adult preparations for their children’s dosing. This led to wrong dosing due to a variety of reasons, from miscalculating the proper translation from milligrams to kilograms to using the wrong syringe size.

## The Importance of Accurate Dosing

Small changes in the dose may mean the difference between safe and potentially dangerous in terms of health consequences. Jonathan Zipursky, a clinical pharmacologist and toxicologist at the Sunnybrook Health Sciences Centre and main author of the study, said there are real consequences to administering the wrong dose to children, so parents have to be extra careful when doing calculations or consult a health-care provider for advice.

## The Need for Forecasting Supply-Demand Mismatch

The study published today in the New England Journal of Medicine (NEJM), sheds some light on the importance of drug shortages, especially in vulnerable populations like children, and the importance of forecasting potential supply-demand mismatch. During the countrywide shortage of children’s painkillers, the OPC created a dosing guide for parents.

## The Scope of the Problem

However, the study only reflects a small portion of the dosing errors during the drug shortage, Thompson told adding she believed the problem was “much bigger.” Not every dosing error is reported because there is no obligation to disclose them, there is a lack of knowledge about poison centres, and parents might go straight to a pharmacist or hospital rather than call.

## Seeking Help

The OPC is one of five poison centres in Canada covering 15.6 million people across Ontario, Manitoba and Nunavut. Similar to its regional counterparts, it provides telephone-based front-line service from nurses and pharmacists with specialised training in the effects of poisons seven days a week, 24 hours a day. If you need to call a poison control centre in your area, you can find a list of locations here or you can call the national line at 1-844-764-7669.

The study highlights the importance of accurate dosing and the need for forecasting potential supply-demand mismatch in order to prevent medication shortages and their associated risks. Parents and caregivers are urged to consult healthcare providers for advice on dosing and to seek help from poison control centres in case of unintentional dosing errors.

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