Are you prescribing ADHD medication correctly? Poison centers see a 300% rise in reports related to possible prescription errors

A new study published by the American Academy of Pediatrics (AAP) reveals large spikes in ADHD medication-related errors since 2000, which have led to an increase in errors reported to United States poison centers.^[] 

The study looked at US poison center data from 2000 to 2021 and found that a total of 124,383 ADHD medication–related therapeutic errors had been reported within that period. Over the more than two decades evaluated, annual frequency of ADHD medication–related errors reported to poison centers increased by almost 300%.

The research suggests that the rise may be influenced, in part, by increases in childhood ADHD diagnoses. Higher numbers of diagnoses can lead to more prescriptions, and high numbers of prescriptions may lead to increased chances of medication-related mistakes. Some experts suspect these mistakes are caused by a lack of diligence and individualized care by prescribers and pharmacies.^[][]

“From doctor to nurse to pharmacist, human error is usually the primary reason for medication errors,” says Raafat W. Girgis, MD, a triple board-certified psychiatrist at the rehab center Moment of Clarity. “Most, if not all, medication errors can be prevented with the proper focus.”

Healthcare workers, patients, and caregivers should all be on guard to catch these errors, Dr. Girgis adds. By following steps like double-checking medication labels and following dosage instructions, it is often a team effort to ensure the patient’s “life and well-being is a priority at all times,” he says.

The study researchers also describe these errors as preventable. They advocate for giving more attention “to patient and caregiver education and development of improved child-resistant medication dispensing and tracking systems.” 

What types of medication errors occur?

Of the types of medication error reports, the most common scenarios involving ADHD medication errors included medication being “inadvertently taken” by or given to children twice, children inadvertently taking or being given someone else's medication, and the wrong medication being taken or given to children. In most of the reported scenarios, children were not referred to hospital settings and did not experience serious adverse outcomes. Of those who did experience serious adverse outcomes, children younger than six years old were most at risk.

In addition to the above, Dr. Girgis says that patients or caregivers may inadvertently make dosage mistakes when taking or administering medication at home. Providers should educate patients and caregivers on how to properly take or administer medication before sending them off with a prescription, he adds. Some mistakes he says he notices are:

1. Chewing pills: While some medication is safe to chew, this is not true of all medications. Certain ADHD medications “should never be chewed, cut, or crushed,” as this may change how the body absorbs the substance.

2. Cutting up pills: Sometimes, doctors or pharmacists advise patients to split their pills. If doing so with medical expertise, this is OK. However, not all pills are safe to cut, as some are “specially coated to be long-acting or to protect the stomach.” In addition to telling patients whether they can cut a pill, it can be a good idea to let them know if doing so is dangerous.

3. Using incorrect measuring devices: If taking a liquid medication, it’s important to measure out the substance with the cup that came with the medication or an oral syringe for measuring, which is available at most pharmacies. It can be important to remind patients of this, as some think that “tablespoons” in their silverware drawer are compatible with measuring spoons; unfortunately, these are not always accurate

Dr. Girgis says that he encourages patients and/or caregivers to practice organizational tools to avoid medication or dosage errors and that other providers may want to do the same. Some tips include keeping an up-to-date list of all medications that the patient is taking, saving the information sheets that come with medications, and double-checking medication labels at the pharmacy.

While it's hard to deny the presence of medication errors, it's important to remember that these can be avoided—and to encourage patients not to fear taking a prescription that is meant for them. Slowing down and giving individualized attention to the prescription and medication-education process is a good step toward ensuring safety.

“Medication is a marvelous thing when we are talking about the severity of the diagnosis symptoms,” Dr. Girgis says.