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Pediatric IV acetaminophen dosing errors continue to occur in hospitals, revealing a persistent but preventable source of iatrogenic overdose in children.
A new study warns that intravenous (IV) acetaminophen overdoses in children continue to occur in hospitals, highlighting an ongoing risk of preventable medication errors in acute care settings.
Researchers launched the investigation after identifying three pediatric overdose cases in early 2025, in which kids received between 3 and 10 times the intended IV acetaminophen dose. Two of those patients required treatment with N-acetylcysteine (NAC), the antidote used to prevent liver toxicity from acetaminophen overdose.
To assess whether these incidents reflected a broader problem, investigators conducted a 14-year retrospective review of calls made by healthcare facilities to the California Poison Control System (CPCS) involving IV acetaminophen dosing errors in kids between 2011 and 2024. Data extracted included patient age, hospital setting, intended and administered doses, acetaminophen levels, laboratory results, use of NAC, and clinical outcomes. The review uncovered 42 additional overdose cases linked to IV dosing mistakes (Table 1).
Medication errors occurred across multiple hospital settings, most commonly in operative or perioperative areas, which accounted for 13 cases. Another 12 cases were reported in emergency departments, 11 on pediatric inpatient units, and five in intensive care units, while four cases occurred in unspecified hospital areas.
Two additional children identified in the review also received NAC therapy. Despite the severity of some overdoses, researchers reported that none of the 45 affected children experienced long-term adverse outcomes. The authors noted that determining the likelihood of toxicity and deciding when NAC treatment is prudent can still be cumbersome in pediatric IV acetaminophen overdoses. They emphasized that additional prevention strategies are needed to reduce these infrequent but potentially serious medication errors in acute care environments.
Hospital Pediatrics
Pediatric Intravenous Acetaminophen Overdoses: A Continuing Iatrogenic Problem
Alexandra Moseanko et al.
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