Clonidine Overdose: A Review of Pharmacology and Medication Error

Medication error is the most common medical error and disproportionately affects pediatric patients. Physicians have a responsibility to understand root causes for medication error and common prevention strategies. Further research in this field is imperative to prevent medication errors resulting in adverse patient events. This article uses a case of potential clonidine toxicity that presented to the emergency department to illustrate and review these concepts. Given that clonidine is being prescribed to both pediatric and adult patients for expanding clinical indications, children are at higher risk for potential overdose. Therefore, a brief review of clonidine toxicity and its management is also provided.