Is there a rise in ADHD medication errors?

Written by: Dr Mohan Gondhalekar
Edited by: Aoife Maguire

A new study has demonstrated that errors in ADHD medication errors are on the rise, principally due to the increase in the number of ADHD prescriptions. Leading consultant old age and general adult psychiatrist Dr Mohan Gondhalekar explores this issue.




What are the statistics shown by the survey regarding errors in attention deficit hyperactivity disorder (ADHD) medications?


According to a new study, errors in attention deficit hyperactivity disorder (ADHD) medications have risen nearly 300% in the past twenty years among people under the age of 20.


Although there isn't a standardised definition for what qualifies as a medication error, a frequently referenced definition comes from the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), which states that it is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”


The authors of the study state that the increase in medication errors is most likely connected to a corresponding increase in the number of ADHD medication prescriptions, and state that the majority of errors did not have a significant impact.


However, considering that medication errors are avoidable, experts emphasise the importance of developing initiatives to educate both patients and caregivers. Additionally, experts must focus on enhancing systems for monitoring and dispensing medications.


What are the common types of medication errors?


There are many ways in which medications can be used incorrectly, and such errors are not exclusive to ADHD medications.


As indicated by the study, the primary error often involves unintentionally administering the medication twice. Another potential error involves dispensing an incorrect quantity of liquid medication, which could result from confusion related to decimal points. For instance, administering 5ml of liquid instead of the prescribed 0.5ml, or confusing volume measurements like millilitres with weight measurements such as milligrams.


An example of a potential error is that if the formulation of a liquid medication at 10 mg/5 mL, and a patient is prescribed 5 mg of the medication, they should ideally consume 2.5 mL of the liquid. Nonetheless, there's a risk of confusion, leading the patient to mistakenly take 5 mL, doubling the intended dosage of 5 mg.


Furthermore, errors may take place due to changes in prescription. For example, if an individual is currently consuming two 10mg pills daily, and the healthcare provider intends to streamline the dosage to a single 15mg pill. If the patient overlooks this change, there's a risk of them continuing to take two pills, resulting in an unintended double dose of 15 mg—10 mg more than their previous prescription.


Unfortunately, there is currently a shortage of ADHD medication in the UK, leading to frequent medication changes and posing the risk for errors to be made.


What type of risks do medication errors pose for people with ADHD?


Luckily, the majority of these errors do not lead to any harm. If someone takes an excessive dose of stimulants commonly prescribed for ADHD, symptoms such as palpitations, stomach aches, and headaches may occur.


Additionally, they may feel irritable, moody, or struggle to sleep. These side effects typically resolve within 12 to 24 hours, and medical intervention is rarely necessary.


Nonetheless, it is crucial for families to consistently inform their prescriber or the designated after-hours contact if the patient has unintentionally exceeded the prescribed medication dosage.


However, some doctors say that errors in the other direction, although not immediately harmful, may result in ineffective treatment in the long run. Inaccurate dosages or missed medications can lead to insufficient symptom management, giving rise to academic, social, and emotional difficulties for individuals with ADHD. Persistent medication errors of this nature can impact a person's overall health and well-being.


What can people do to lower their risk for medication errors?


There are four ways in which people can reduce their risk for medication errors in four ways.


Be informed


People who take ADHD medication should know the name of the drug they’re taking as well as:


  • doses
  • indications
  • contraindications
  • side effects
  • possible interactions


It is vital for patients to read labels and leaflets carefully and ask questions if they have any doubts or concerns.

It is a good idea to keep a list of all your medications and share it with your doctors.


Be involved


Patients should take an active role in making decisions about their treatment and medications, discussing the benefits and risks of different options with their healthcare providers.


It is also important to follow instructions given and report back any problems or changes in their condition to the doctor.


Be vigilant


It is crucial to check medications before taking them or giving them to others. Some things to look for include signs of tampering or damage or medications past their expiration date.

He also urges the use of appropriate measuring devices, such as syringes or measuring spoons, to ensure that the proper amount of medication is dispensed.


Be proactive


Additionally, it is essential to ask for medical help if you experience any problems with medications, including issues such as adverse effects, allergic reactions, or potential drug interactions. Additionally, individuals should communicate with their healthcare providers about all the medications they are using, including over-the-counter products, herbal remedies, vitamins, and supplements.


Although errors can occur, mistakes can be avoided, and patients have the ability to play an active part in safeguarding themselves.




If you would like to book a consultation with Dr Gondhalekar, do not hesitate to do so by visiting his Top Doctors profile today.

By Dr Mohan Gondhalekar

Dr Mohan Gondhalekar is a highly accomplished and dedicated consultant old age and general adult psychiatrist based in London. Dr Gondhalekar specialises in a wide range of areas including adult ADHD, anxiety, adjustment disorder, PTSD, OCD, panic attacks, personality disorders, memory disorders, psychosis, bipolar affective disorder, and depression.
Dr Gondhalekar undertook his medical studies at the University of Birmingham, graduating with a Bachelor of Medicine and Bachelor of Surgery (MBChB) in 2011, following his Intercalated Degree in Bachelor of Biomedical Sciences (BMedSci, History of Medicine) which he received from the same institution in 2009. He later became a member of the prestigious Royal College of Psychiatrists (MRCPsych) in 2016.
Dr Gondhalekar underwent postgraduate core psychiatry and dual higher specialist training at the Herefordshire and Worcestershire Health and Care NHS Trust, as well as the Essex University Partnership NHS Trust. He currently holds the position of consultant psychiatrist at the North-East London Foundation NHS Trust within Community Old Age Psychiatry, where his expertise has positively impacted countless patients.
Beyond clinical practice, Dr Gondhalekar actively contributes to the field by teaching, working to shape the minds of future psychiatrists. He served as an academic tutor at the University of Birmingham, School of Medicine, and was involved in supervising medical students in their 3rd, 4th, and 5th years. His dedication to mental health extends to positions in public organisations, where he currently serves as an external clinical advisor for mental health at the Parliamentary Health Service Ombudsmen and as a member of the National ECT Accreditation Committee.

View Profile

Overall assessment of their patients

  • Related procedures
  • Relationship counselling
    Psychiatric Treatment
    Paediatric psychiatry
    Toxic Addiction (alcoholism)
    Psychotic disorders
    Eating disorders
    Obsessive compulsive disorder (OCD)
    This website uses our own and third-party Cookies to compile information with the aim of improving our services, to show you advertising related to your preferences as well analysing your browsing habits. You can change your settings HERE.