A 3-year-old girl received treatment in a pediatric Emergency Department (ED). Nurses in the ED had drawn up saline flush syringes from multiple dose vials of saline to clear her intravenous (IV) line. Apparently, syringes of vecuronium had been prepared for another patient who was treated before the 3-year-old arrived at the hospital. One syringe filled with vecuronium had gone unused and it was somehow mixed with the saline supplies. The syringe was hand labeled similarly to the saline syringes. As a result, a syringe containing vecuronium was used to flush the IV line of the 3-yearold girl. The child quickly became frightened and then flaccid. When all respiratory efforts ceased, she was immediately intubated and ventilated. Personnel identified the error after closer inspection of the syringes. The patient was treated supportively and fortunately suffered no permanent harm. The child's father who was present at the time of the incident reported it to the local press and the event received extensive local media attention. 1 A 5-year-old boy received ketamine for a laceration repair in the ED. The physician ordered 5 mg/kg; the patient received 50 mg/kg due to a ''math error.'' Although the patient experienced no respiratory depression, the physician chose to intubate the child as a precaution. He was discharged from the ED awake and alert 5 hours after receiving the medication. Fortunately, he suffered no long-term sequelae. 2 A 4-year-old boy was given ketamine in the ED for a fracture reduction. The order was written for 1 mg/kg of ketamine; the child received 10 mg/kg of the drug due to inadvertent use of the 100-mg/mL formulation of ketamine instead of the 10-mg/mL formulation. Two minutes after injection of the medication, the child experienced respiratory distress with oxygen desaturation to 65%. Ventilation was assisted for 9 minutes, and was then followed by normal spontaneous respirations. The patient was observed in the ED for 3 hours following receipt of the drug. He was well at discharge and suffered no long-term sequelae from the medication error. 2

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This continuing feature will focus on recent advancements in the areas of pediatrics and neonatal pharmacology and on methods for reducing medication error risk in this patient population. Most pharmacological agents are designed with the adult in mind, and there is little literature-based data from which to derive dosing schedules and proper drug administration techniques for the pediatric and neonatal patient. Moreover, pharmacological response in this group is not well understood. We hope that this feature will help you provide pharmaceutical care to this high-risk population. Direct questions or comments to hospitalpharmacy@drugfacts.com.