A recent study, conducted at Nationwide Children’s Hospital in Columbus, Ohio and published in Pediatrics, highlights a significant and concerning increase in out-of-hospital ADHD medication errors among individuals younger than 20 years old. According to the study's findings, the rate of medication errors involving ADHD medications escalated by 299% between 2000 and 2021. For context, ADHD (Attention-deficit/hyperactivity disorder) is one of the most prevalent pediatric neurodevelopmental disorders in the United States. Approximately 3.3 million children, or around 5% of all U.S. children, are currently under medication for treating ADHD symptoms.

The research analyzed data from U.S. poison centers between 2000 and 2021, revealing 87,691 reported instances of medication errors involving ADHD drugs. This equates to an average of 3,985 cases per year, and a notably high 5,235 cases in the year 2021 alone—translating to one child every 100 minutes. The demographic data from the study indicates that males were more often the victims of such errors, making up 76% of cases. Furthermore, children between the ages of 6-12 constituted 67% of all reported errors. A staggering 93% of these errors occurred within the home environment.

The study outlined the most common types of medication errors as follows: 

• 54% involved double-dosing or inadvertently taking or giving the medication twice.
• 13% occurred due to mistakenly taking or giving someone else's medication.
• Another 13% were the result of administering or taking the wrong medication.

Notably, while the majority of these errors did not necessitate hospital treatment, 2.3% led to hospital admission, including 0.8% to critical care units. Additionally, 4.2% of cases were linked to serious medical outcomes such as agitation, tremors, seizures, and changes in mental status. Children under 6 years were found to be twice as likely to experience a severe medical outcome and three times more likely to require hospital admission than those aged 6-19.

To address this issue, experts have urged for comprehensive education for patients and caregivers. Moreover, they advocate for the development of improved child-resistant medication dispensing and tracking systems. The transition from traditional pill bottles to unit-dose packaging, like blister packs, is also recommended as it could aid in preventing double-dosing errors.

Though the home remains a primary focus for prevention, researchers argue that schools and other places where children and adolescents spend considerable time should not be neglected in medication safety efforts.

This alarming rise in ADHD medication errors points to the urgent need for actionable steps in both patient education and medication dispensing methods.

For more information, visit Nationwide Children's Hospital.