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Medication error is a serious problem in the care of children.12 Based on a report from US poison control centres and the American Academy of Pediatrics, 11% of children under the age of 6 years who are exposed to pharmaceuticals experience a medication error (incorrect medication, incorrect dose or incorrect route of administration).13 This report analyzed 238 instances of serious medication error in children under six years of age reported to poison control centres across the US between 2000 and 2004