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Reducing the Risk of Harm From Medication Errors in Children



Medication errors affect the pediatric age group in all settings: outpatient, inpatient, emergency department, and at home. Children may be at special risk due to size and physiologic variability, limited communication ability, and treatment by nonpediatric health care providers. Those with chronic illnesses and on multiple medications may be at higher risk of experiencing adverse drug events. Some strategies that have been employed to reduce harm from pediatric medication errors include e-prescribing and computerized provider order entry with decision support, medication reconciliation, barcode systems, clinical pharmacists in medical settings, medical staff training, package changes to reduce look-alike/sound-alike confusion, standardization of labeling and measurement devices for home administration, and quality improvement interventions to promote nonpunitive reporting of medication errors coupled with changes in systems and cultures. Future research is needed to measure the effectiveness of these preventive strategies.
Health Services Insights 2013:6 47–59
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Health Services Insights
Health Services Insights 2013:6 47
Reducing the Risk of Harm From Medication Errors in Children
Daniel R. Neuspiel1,2 and Melissa M. Taylor1
1Levine Children’s Hospital of Carolinas Medical Center, Charlotte, NC, USA. 2University of North Carolina School of
Medicine, Charlotte, NC, USA. Corresponding author email:
Abstract: Medication errors affect the pediatric age group in all settings: outpatient, inpatient, emergency department, and at home.
Children may be at special risk due to size and physiologic variability, limited communication ability, and treatment by nonpediatric
health care providers. Those with chronic illnesses and on multiple medications may be at higher risk of experiencing adverse drug
events. Some strategies that have been employed to reduce harm from pediatric medication errors include e-prescribing and comput-
erized provider order entry with decision support, medication reconciliation, barcode systems, clinical pharmacists in medical set-
tings, medical staff training, package changes to reduce look-alike/sound-alike confusion, standardization of labeling and measurement
devices for home administration, and quality improvement interventions to promote nonpunitive reporting of medication errors coupled
with changes in systems and cultures. Future research is needed to measure the effectiveness of these preventive strategies.
Keywords: patient safety, medical error, medication error, electronic health record
Neuspiel and Taylor
48 Health Services Insights 2013:6
Medication errors frequently affect pediatric patients,
in both the outpatient and inpatient setting, as well as
in the home environment. These errors occur at all
stages in medication use: ordering, transcribing, dis-
pensing, and administration. Children may be at par-
ticularly increased risk for medication errors due to
varied sizes, stages of development, communication
barriers, and treatment by health care staff unfamil-
iar with this age group. This review will summarize
current knowledge on medication errors in pediatrics
and will review strategies that have been employed to
reduce the harm from these events.
We conducted a comprehensive search of MEDLINE
(1966 through 2012) using the medical subject head-
ing terms medication error, involving humans, pub-
lished in English with abstracts and limiting the age
group to 0 to 18 years. This initial search yielded 730
references, which were reviewed by the authors. We
omitted individual studies that were included in other
cited systematic reviews, as well as other publica-
tions deemed to be nonrelevant to the goals of this
review by the authors. Further studies were identied
by examining the references of the index articles.
Medication Errors in Outpatient
Most pediatric encounters occur in ofces and clin-
ics, and medical errors were initially reported in
this milieu by Mohr et al.1 Of 147 medical errors
reported from 14 pediatric practices, 47 were medica-
tion errors, among which 55% were related to order-
ing, 30% to failure to order, 11% to administration,
2% to transcribing, and 2% to dispensing. Since no
denominator data were collected, error rates could
not be determined.
Among 1933 randomly selected children receiving
new prescriptions using automated pharmacy data
from 3 health maintenance organizations, McPhillips
et al2 determined that 15% of children had potential
dosing errors: 8% overdoses and 7% underdoses.
Dosing errors were higher (33%) in children weighing
less than 35 kg. Among children under 4 years of age,
20% experienced dosing errors compared with 13%
of children between 4 and 12 years of age. Patients
receiving 5 prescriptions had more dosing errors
than children with a single prescription. Medications
most frequently overdosed were analgesics (15%
overdosed), and the most frequently underdosed
medications were antiepileptics (20% underdosed).
There were no reductions in error rates in the site
using an electronic prescription writer.
In a prospective cohort study at 6 ofce practices
over 2 months,3 there were 57 (3%) preventable
adverse drug events (ADEs) among 1788 patients. No
events were determined to be life threatening, but 8
(14%) were deemed serious. Forty (70%) were related
to parental drug administration. Children receiving
multiple prescriptions were at greater risk of errors.4
Children receiving >1 medication and aged <5 years
were associated with risk of medication administra-
tion errors.5 Among medication errors, 94% with
minimal potential for harm and 60% of near misses
occurred at the point of prescribing, most frequently
due to inappropriate abbreviations, dosing errors, and
Among pediatric residents in an outpatient clinic,
Condren and colleagues7 found errors among 9.7%
of prescriptions. The most frequent error was due to
incomplete information entered (42%), followed by
medication dosing errors (34%). In a study of medi-
cal errors reported in a pediatric outpatient teaching
practice,8 of 216 total errors in a 30 month period, 24
were related to medication prescribing or dispensing
and 21 to vaccines.
Medication Errors in Pediatric
Emergency Departments
A number of reports have detailed medication errors
among children and adolescents in emergency depart-
ment settings. Among standing orders for acetamin-
ophen in a pediatric emergency department in a
1-week period, there were 122 (78%) correct doses,
15 (10%) underdoses, and 19 (12%) overdoses.9 The
rectal route was associated with signicantly greater
overdoses (35%) than with orally administered acet-
aminophen (8%). In another pediatric emergency
department, among 1532 children, 10.1% had medi-
cation prescribing errors.10 Risk for error was greater
when medications were ordered by trainees or for
seriously ill patients.
Vilá-de-Muga et al11 described medication errors
occurring in a pediatric emergency department in a
tertiary children’s hospital. In 377 records where
Reducing the risk of harm from medication errors in children
Health Services Insights 2013:6 49
treatment was prescribed, 92 errors (15%) were
detected. All were prescription errors and none were
considered severe. Error rates were higher among
less experienced residents, and more errors occurred
on weekends and nights.
Outpatient Medication Errors
in Special Groups of Children
Some children, particularly those with chronic ill-
nesses and on multiple medications, may be at special
risk of medication errors. Outpatient oral chemother-
apy medication errors were studied in children with
acute lymphoblastic leukemia over a 2-month period
at one center.12 At least 1 error occurred in 17 of 172
medications (9.9%). Of the 17 errors, 12 were related
to administration and 5 to prescribing, but none to
pharmacy dispensing. All errors were related to either
incorrect dosing or failing to administer an indicated
medication. At least 1 medication error was experi-
enced by 13 (18.8%) of the 69 study patients.
In 52 home visits of children with sickle cell dis-
ease and seizure disorders,13 61 medication errors were
detected among 280 reviewed medications, including
31 with potential injury and 9 with actual injury to the
child. Frequent error sources included parents failing
to ll prescriptions or to change doses due to com-
munication barriers. The errors led to further testing
or continued pain, inammation, seizures, vitamin
deciencies, or other injuries. Communication fail-
ures between 2 parents occurred in some cases, with
subsequent administration errors and difculty in
medication preparation for administration. When par-
ents used support tools for home medication use (eg,
alarms or reminders), error rates were signicantly
less than among parents not using such tools (44%
vs 95%, respectively). The patients’ physicians were
unaware of 80% of the errors detected.
Among both inpatient and outpatients, 451 medica-
tion errors involving antidepressants in children under
18 years were reported from 2003–2006 , utilizing the
United States Pharmacopeia MEDMARX database
(an anonymous, voluntary national error reporting
system).14 Of these, 95% reached the patient, 6.4%
required increased monitoring and/or treatment, and
77% involved off-label medication use. The errors
occurred at the point of medication administration
(33%), dispensing (30%), transcribing (28%), and
prescribing (7.9%). The most frequent medications
involved in errors were sertraline (20%), bupropion
(19%), uoxetine (15%), and trazodone (11%). In the
outpatient setting, there were more dispensing errors
and mistakes due to inaccurate or omitted transcrip-
tion compared with the inpatient location. Since there
was no denominator information, error rates could
not be determined.
Communication Barriers Between
Health Care Providers and Caregivers
Since children depend on others for appropriate med-
ication administration, communication barriers with
their caregivers are of particular concern. Yin et al15
evaluated parental liquid medication administration
errors associated with dosing instrument type and
health literacy levels. The accuracy of 302 parents
was observed in administering a 5 mL dose with cup
with printed calibration markings, cup with etched
markings, dropper, dosing spoon, and oral syringes
with and without bottle adapters. Parents had lowest
accuracy using a cup with printed markings (30.5%)
and cup with etched markings (50.2%). More than
85% of parents dosed accurately using the other
measuring devices. After adjusting for confounders,
cup utilization was associated with increased odds of
making a dosing error compared with oral syringe.
Cups were also more likely than oral syringes to be
associated with making large dosing errors. Dosing
errors occurred more frequently with limited health
literacy. Sobhani and colleagues16 also determined
that adults were able to measure liquid acetamino-
phen more accurately using an oral syringe than a
cup, but only two-thirds of participants demonstrated
acceptable dose accuracy with the syringe.
The frequency of inconsistent dosing directions
and measurement devices among pediatric over-the-
counter (OTC) medications were evaluated during
the year prior to the 2009 release of US Food and
Drug Administration (FDA) new recommendations
for greater consistency and clarity in dosing direc-
tions and measuring devices.17 Measuring devices
were included with 148 of 200 products (74%).
There were inconsistencies between medication dos-
ing directions and measurement device markings
in 146 of 148 products (98.6%), including missing
(24.3%) and superuous markings (81.1%). Eleven
products (5.5%) used atypical measurement units.
Nonstandard abbreviations for milliliter were used
Neuspiel and Taylor
50 Health Services Insights 2013:6
in 97 products (49%). Abbreviations were not fully
dened in most products. The authors concluded that
at the time of the new FDA recommendations, best-
selling pediatric OTC medications were using highly
variable and inconsistent dosing directions and mea-
suring devices.
Wallace et al18 studied the readability of retail
pharmacy–generated consumer medical information
and the features of measuring devices for oral liquids.
Investigators lled prescriptions for prednisolone and
amoxicillin at 20 different pharmacies in Colorado,
Georgia, and Tennessee. Many information materi-
als were at a 9th to 11th grade readability level, too
high for many parents, and 3 pharmacies provided no
materials. One-third of pharmacies provided measur-
ing devices that needed multiple measurements for
the prescribed doses.
Leyva et al19 evaluated how well Bronx Spanish-
speaking Latino parents of children 5 years and
younger understood written medication instructions.
After receiving instructions on administration of
ferrous sulfate, only 22% of parents demonstrated
correct medication administration in amount and fre-
quency. Those reporting comfort speaking English
were more likely to demonstrate correct medication
dosing (50% vs 21%) and correct frequency (93% vs
51%). Education level and comfort speaking English
independently predicted correct medication dosing.
Sharif and Tse20 surveyed 316 pharmacies in the
Bronx to assess computer software used to generate
Spanish medication labels. Among 286 participating
pharmacies, 209 (73%) provided medicine labels in
Spanish. Pharmacies providing Spanish labels mainly
(86%) used computer programs to generate them.
Employees translated 11% of labels, and 3% used
professional interpretation services. The investigators
evaluated 76 medication labels generated by 13 dif-
ferent computer programs and found that 32 Spanish
labels (43%) included incomplete translations (mix-
ture of English and Spanish), and 6 labels contained
misspellings or grammar errors. The overall error
rate was 50%. The investigators concluded that while
pharmacies were able to provide Spanish labels, the
translation quality was inaccurate and potentially
Flores and Ngui21 also identied racial, ethnic,
and language barriers as contributors to increased
risk of pediatric errors. Yet in 2004, the majority of
pediatricians reported using untrained interpreters to
communicate with patients and their families with
limited English prociency.22
Typically, adolescents are afforded increased
responsibility for self-care, with less supervision by
parents. This transition of responsibility may increase
their risk for home medication errors. Wilson and
colleagues23 studied misconceptions and knowledge
gaps among teens about OTC medications. They
determined that 78% of the adolescents had used
OTC medications in the previous month, most fre-
quently ibuprofen and acetaminophen. Although 35%
of teens reported knowing about acetaminophen, 37%
did not know it was the same as Tylenol, and many
had limited knowledge about adverse effects and
contraindications. Hispanic teens reported less use of
acetaminophen and had lower knowledge scores than
other ethnicities.
Lokker et al24 recruited 182 caregivers from clinics
at 3 institutions and questioned them about the use of
4 common OTC medications. Although mean educa-
tion level of caregivers was 12.5 years, only 17% had
higher than ninth grade numeracy skills. While all of
the medications were labeled with advice to consult
a physician for use in children under 2 years, parents
would give these products to a 13-month-old child
over 50% of the time.
Li and colleagues25 found that 51% of surveyed
caregivers gave inaccurate home doses of acetamin-
ophen (62% inaccurate) or ibuprofen (26% inac-
curate), especially to infants younger than 1 year
of age. McEarlean et al26 reported that 53% of chil-
dren received improper antipyretic dosing at home.
Goldman27 noted that 47% of parents gave acetamino-
phen at correct doses, 12% gave overdoses, and 41%,
underdoses. Non-English speaking parents were less
likely to give recommended doses.
Chang et al28 surveyed parents of hospitalized
febrile children under 6 years of age. After being
provided with written medication instructions for
antipyretics, one-third of parents had more than
1 misunderstanding about medication timing and/or
dosage, and almost two-thirds of parents misunder-
stood adverse effects of acetaminophen. Poorer com-
prehension of instructions was associated with lower
education level.
Costelloe et al29 found deciencies in the ability of
parents to measure weights of preschool children at
Reducing the risk of harm from medication errors in children
Health Services Insights 2013:6 51
home for calculation of antipyretic dose. Only 40%
of parents had home scales, and most of these scales
were analog. Research scale weights were heavier
than those from home scales, with a mean difference
of 0.41 kg (95% CI, 0.24–0.74 kg).
Inpatient Medication Errors
In the pediatric inpatient setting, medication errors
have also been frequently reported. Kaushal et al30,31
studied medication errors, ADEs, and potential ADEs
among a prospective cohort of 1120 pediatric patients
admitted to 2 academic medical centers over a 6-week
period in 1999. Among 10,778 medication orders, 616
errors (5.7%) were identied, along with 115 potential
ADEs (1.1%) and 26 ADEs (0.24%). Potential ADEs
were signicantly higher in neonates in the neonatal
intensive care unit. Most potential ADEs occurred at
the drug ordering stage (79%) and were associated
with incorrect dosing, anti-infective drugs, and intra-
venous medications.
Holdsworth et al32 studied adverse drug events in
hospitalized children using record review and staff
interviews in a metropolitan medical center in 2000–
2001. Among 1197 consecutive pediatric admissions
(representing 922 patients and 10,164 patient-days),
ADEs occurred in 6% of admissions and 7.5 times
per 1000 patient-days; potential ADEs occurred in
8% of admissions and 9.3 per 1000 patient-days.
After adjusting for length of stay, risk of ADEs and
potential ADEs was associated with the amount of
medication exposure. Among ADEs, 18 (24%) were
determined to be serious or life threatening.
In 1719 observations involving 336 patients and
485 nurses in a teaching hospital,33 there were 538
pediatric drug administration errors detected, affect-
ing 27% of administrations. These involved timing
(36%), route (19%), dose (15%), unordered drug
(10%), or form of drug (8%). There were fewer errors
associated with intravenous drugs and more errors in
cardiovascular drugs, central nervous system (CNS)
drugs, drugs prepared by pharmacy, and administra-
tion by hospital pool nurse, temporary staff agency
nurse, or nurse intern.
Ghaleb et al34 conducted a systematic review
of investigations of inpatient pediatric medication
errors, including studies using spontaneous report-
ing (10 studies), medication order or chart review
(14 studies), and observation (8 studies). Denitions
and rates of medication errors were variable. The
most common reported type was dosing error, and the
most frequent medications involved were antibiotics
and sedatives.
Wang et al35 studied medication errors and ADEs
among pediatric inpatients in a large academic com-
munity hospital. Among 16,938 medication orders
in 678 admissions, there were 865 medication errors
noted, a rate of 5.2 per 100 orders. Among potentially
harmful prescribing errors, 78% were intercepted by
clinical pharmacists. None of the potentially harm-
ful administration errors were intercepted, and these
accounted for 50% of preventable ADEs.
Ferranti et al36 compared medication-related events
detected by a computerized surveillance system with
voluntary safety reporting over 1 year at a large aca-
demic medical center. Of 849 reports from volun-
tary safety reporting, 93 caused patient harm, with
a rate of 1.8 events per 1000 pediatric patient days.
Among 1537 events detected by computer surveil-
lance, 78 resulted in patient harm, with a rate of 1.6
events per 1000 pediatric patient days. Most frequent
events from safety reporting were failures in the pro-
cess of medication use (27%), drug omissions (16%),
and events related to dose or rate (13%). In the sur-
veillance group, most events involved nephrotoxins
(21%), narcotics and benzodiazepines (19%), and
hypoglycemia (12%).
Chua et al37 described drug administration errors
in 2 pediatric wards. Among 857 drugs administered,
100 (11.7%) had dosing errors. Excluding wrong
time administration errors, the rate was 7.8%. Most
frequent errors were incorrect time of administration
(28.8%), incorrect drug preparation (26%), omission
errors (16.3%), and incorrect dose (11.5%). No errors
were found to be life threatening, but 40.4% were
potentially harmful.
Ghaleb et al38 included chart review, prospective
observation of nurses, and incident reports to deter-
mine the incidence and description of medication
prescribing and administration errors among pedi-
atric inpatients across 5 hospitals in the London
area. They identied 391 prescribing errors, with
an error rate of 13.2%. There were 429 medication
administration errors, with a rate of 19.1% erroneous
Shah et al39 examined 50 random inpatient admis-
sions to an otolaryngology service at a children’s
Neuspiel and Taylor
52 Health Services Insights 2013:6
hospital for medical errors. There were medication-
related errors in 22% of admissions, but only 2
resulted in minor adverse events.
Al-Jeraisy et al40 surveyed medication errors
in a general pediatric ward and pediatric intensive
care unit. Of 2380 medication orders reviewed,
the overall error rate was 56%. Dosing errors were
most frequent (22.1%), followed by errors in route
of administration (12.0%), clarity (11.4%), and
frequency (5.4%). There were less frequent errors
including incompatibility, incorrect drug selection,
and duplicate therapy. Highest error rates were for
electrolytes (17.2%), antibiotics (13.7%), and bron-
chodilators (13.0%).
Subspecialty-Specic Inpatient
Medication Errors
Rinke et al41 studied pediatric chemotherapy errors
utilizing the US Pharmacopeia MEDMARX data-
base. Of 310 error reports, 85% reached the patient,
and additional monitoring or intervention was needed
in 15.6% of events. Most errors (48%) occurred in the
administration phase, and 30%, in drug dispensing
phase. Error types included improper dose or quan-
tity (22.9%), wrong time (22.6%), omission (14.1%),
and wrong administration technique or route (12.2%).
Causes of errors were determined to be performance
decit (41.3%), equipment and medication delivery
devices (12.4%), communication (8.8%), knowledge
decit (6.8%), and written order errors (5.5%). Of
the 5 most serious errors, 4 occurred in community
Alexander et al42 described cardiovascular medica-
tion errors from the US Pharmacopeia MEDMARX
system in patients under 18 years of age. Among 147
facilities, 821 error reports were submitted involving
893 medications. The mean age was 4 years, but the
median was 0.9 years. Most errors occurred during
drug administration, especially related to improper
dosing. There were 5% near misses, 91% errors with-
out harm, and 4% errors with harm but no fatalities.
The most frequent medication type involved in errors
was diuretics, followed by antihypertensives, angio-
tensin inhibitors, β-adrenergic receptor blockers,
digoxin, and calcium channel blockers. The largest
proportion of harmful events occurred with calcium
channel blockers, phosphodiesterase inhibitors, anti-
arrhythmics, and digoxin. More than half of events
were in infants <1 year of age, but the proportion of
harmful events did not differ by age.
Pediatric Critical Care and NICU
Medication Errors
Russell et al43 measured discrepancies between medi-
cation orders for infusions entered into a computer-
ized provider order entry (CPOE) system and the
actual medication being infused as measured by the
programmed settings of the smart infusion pump in
a pediatric critical care unit. Of the 72 medication
observations that revealed order programming dis-
crepancies, 62 (86.1%) of the discrepancies were
due to either unauthorized or omitted medications,
while 10 (13.9%) were due to wrong medication
dose. The medication categories with the most fre-
quent class-specic order-programming discrepan-
cies included anti-infectives (100%), concentrated
electrolytes (46.7%), and anticoagulants (46.2%).
Within the anti-infective and concentrated electrolyte
groups, every discrepancy was identied as an unau-
thorized medication, whereas anticoagulant discrep-
ancies were almost evenly split between unauthorized
and omitted medications. None of the discrepancies
observed within the anti-infective medications, con-
centrated electrolytes, or anticoagulants were found
to be due to a wrong dose. One potential reason for
the discrepancies was communication between phy-
sician and nurse regarding drug dosages without an
order being entered into CPOE.
Stavroudis et al44 assessed risk factors for harmful
medication errors occurring in the NICU setting. In
the MEDMARX database from 1999 through 2005,
6749 NICU medication error reports were reported
from 163 facilities. Approximately half were admin-
istration errors, and human factors were cited as
most frequent cause of errors. Those most likely to
be harmful involved high-alert medications, occurred
in the prescribing phase, or involved equipment/
delivery device failures.
Temporal Differences and Risk
of Inpatient Medication Errors
Miller et al45 sought to determine whether time of day
and weekday versus weekend inuence medication
error rates among pediatric inpatients. The reported
error rate during evenings was signicantly higher
than the rate during the day shift for nurses: 2.12
Reducing the risk of harm from medication errors in children
Health Services Insights 2013:6 53
errors per 1000 doses and 1.17 errors per 1000 doses
dispensed, respectively. There was also an increase
in error rates during evening and night pharmacist
shifts; error rates were 1.01 errors (day), 2.24 errors
(evening), and 1.88 errors (night) per 1000 doses
(P = .002). The error rate during weekends did not
signicantly differ from that during weekdays. Medi-
cation administration errors were the most common
type (56.4%), followed by preparation or dispensing
errors (35.7%). The increase in errors reported during
the pharmacy’s evening shift may be attributable to
the increased number of orders per pharmacist and
nursing staff member. Also of note, error rates were
highest during weekend rst shifts, a time when fewer
pharmacists were available.
Obesity as Risk Factor for Inpatient
Medication Errors
The differences in mean error rates per admission for
analgesics and antimicrobials for overweight/obese
(BMI $85th percentile) patients 5 to12 years of age
versus control (BMI ,85th percentile) groups was
studied in a tertiary care academic hospital.46 Overall,
12.9% (109/847) of the drugs were dosed incorrectly
in the overweight/obese group compared with 10.3%
(157/1526) of the medications in the control group.
Evaluation of mean error rates per admission between
groups revealed a statistically signicant increase in
overall mean errors for the overweight/obese versus
control group. Underdosing occurred signicantly
more often in the overweight/obese group. However,
no signicant difference was found in mean overdose
error. The mean overdose and underdose error rates
of antimicrobials were signicantly higher for the
overweight versus control group.
Tenfold Errors
Doherty et al,47 in an academic, university-afliated
pediatric hospital, retrospectively evaluated all
medication-related incident reports describing ten-
fold medication errors. Incorrect programming of
infusion pumps was the most frequent error source.
The omission or addition of zeroes, interswapping
of infusion rates, and simultaneous programming
of multiple infusion rates were the most frequently
identied error mechanisms. Overriding of alarm
limits, paper-based ordering, and urgent clinical sce-
narios were frequently identied as medication error
enablers. Opioids were the most frequently reported
drug class, and morphine was the most frequently
reported medication.
Reducing Harm From Pediatric
Medication Errors
Though investigators have mentioned many points of
the medication prescribing, dispensing, and admin-
istration cycle as ripe for intervention in reducing
errors and subsequent patient harm, few of these
potential interventions have been well studied to date.
Although electronic health records (EHRs) and elec-
tronic prescribing may improve patient safety, their
recent rapid time frame for implementation may have
the unintended consequence of increasing errors, and
new error types associated with this technology have
emerged. E-prescribing has the potential to improve
patient safety, particularly if the program is incorpo-
rated into an EHR, with access to patient medication
histories, allergies, and clinical decision support.
Kaushal et al48 conducted a prospective nonrandom-
ized study using pre-post design of 15 e-prescribing
adopters and 15 concurrent controls using paper-
based prescriptions. Among the adopters, the error
rate decreased from 42.5% errors (per 100 prescrip-
tions) at baseline to 6.6% errors at 1 year (P , .001).
For nonadopters, error rates remained high, with
37.4% errors at baseline and 38.4% errors at 1 year.
All errors related to illegibility were eliminated with
e-prescribing, as were most rule violations (failure to
follow strict prescribing rules that were unlikely to
result in harm).
Van Rosse et al49 conducted a systematic review to
evaluate the impact of CPOE on medication prescrip-
tion errors, ADEs, and mortality in pediatric inpa-
tients. Among 12 studies meeting inclusion criteria, 8
were from ICUs and 4 were pediatric inpatient stud-
ies. There was a signicant risk of medication pre-
scription errors with use of CPOE, but no reduction
in ADEs or mortality. The implementation process of
CPOE was found to be a critical factor in effective-
ness on qualitative assessment of the studies.
Stultz and Nahata50 provide a systematic review
of studies analyzing the effect of implementing
computerized clinical decision support (CCDS),
often in conjunction with CPOE, on appropriate
Neuspiel and Taylor
54 Health Services Insights 2013:6
medication use in pediatrics. They found that differ-
ent functionalities of clinical decision support have
shown different results, with few studies showing
improved patient outcomes. Specically, they found
the following:
• CCDS, CPOE, or a combination of both is associ-
ated with decreased ADEs and error rates.
• Alerts to unnecessary duplicate medication have
not shown consistent benets.
• Medication allergy alerts are often overridden and
have not shown the ability to distinguish between
major and minor allergic reactions or between
allergic and adverse reactions.
• The effectiveness of drug interaction alerts have
not been fully evaluated in pediatrics.
• Computerized dosing calculators have been help-
ful in reducing dosage errors.
• Dose range alerts have helped to lower dosage
errors in some studies.
• The impact of weight verication and weight range
alerts on appropriate pediatric dosing has not been
• Evaluations of alert overrides or including clinician
rationales for overrides have not shown benet in
improved patient outcomes but have demonstrated
some limitations of CCDS systems.
• The use of medication order sets has shown some
benet in implementing evidence-based care, but
there are no data on improved pediatric outcomes.
• Providing evidence-based reminders may result in
better adherence to evidence-based guidelines.
• Provision of treatment recommendations as part
of CCDS has shown variable results in improving
guideline adherence and patient outcomes.
• Centers that incorporate parents and other care-
givers in CCDS, such as kiosks and computer-
assisted telephone interviews, have not shown
benet in patient satisfaction or prescription error
Abramson and Kaushal51 reviewed the impact of
CPOE and noted its potential for improving pediatric
patient safety while acknowledging its unintended
consequences. They observed that most research
on the effectiveness of CPOE has been on reduc-
ing prescribing errors and called for future efforts to
evaluate the CPOE with CCDS features on patient
Medication Reconciliation
Medication reconciliation tools may reduce medi-
cation errors, particularly during transitions of care.
Since 2005, medication reconciliation has been a
national patient safety goal of The Joint Commis-
sion.52 The use of medication reconciliation in pediat-
rics has primarily focused on the inpatient setting, but
its use is also valuable in ambulatory care. Rappaport
et al53 describe a quality improvement intervention to
increase use of a medication reconciliation tool in a
multispecialty children’s integrated health care net-
work. Over a 5-year period, completion of the medi-
cation reconciliation tool increased from 0% to 71%,
although it remains unclear whether this had a posi-
tive impact on patient outcomes.
Stone et al54 conducted a quality improvement study
to evaluate medication reconciliation in children with
complex conditions in a children’s hospital using 5
different information sources: parents, pharmacy, pri-
mary provider, last admission record, and admitting
history. In 219 admissions, there were 23 children
identied with complex medical conditions, with
an average of 5.3 chronic medications. Medication
reconciliation took a mean time of 90 minutes.
Among 182 admission medications, 39 errors (21%)
were identied, including 17 omissions affecting 13
patients. In 5 instances, the estimated clinical risk of
an adverse drug event was serious or life threatening.
No single information source had optimal availabil-
ity, sensitivity, or specicity.
New Types of Errors Related to Health
Information Technology
Sittig and Singh55 dened some common errors
associated with health information technology: com-
puter or network malfunction, truncated input data,
inability to order allowable item, incorrect default
dose for medication, data entered under wrong
patient name, incorrect merge of 2 patients’ data,
critical abnormal test result alerts not followed up,
discontinuation of medication without notifying
staff, and billing requirements leading to inaccurate
Singh56 described additional potentials for errors
with EHR use. Increased accessibility of informa-
tion may reduce diagnostic errors, but it also creates
the potential to overlook important data. It remains
Reducing the risk of harm from medication errors in children
Health Services Insights 2013:6 55
unclear to what extent clinicians should review the
entire computer record. Precompleted templates in
an EHR are potentially problematic because these
notes may contain incorrect information that is easily
overlooked. Templates may also import test results
that may not have been reviewed. Delayed or lack of
follow-up of abnormal laboratory results is another
common source of error with EHR use. Additional
legal, ethical, and nancial challenges have been
described with the implementation of EHR.57
Barcode Systems
Morriss et al58 studied the effectiveness of a barcode
medication administration system on reducing medi-
cation errors in an NICU in an academic medical
center using a prospective cohort design. After con-
trolling for the number of daily medication doses per
subject, the barcode system was associated with a
47% reduced risk of preventable ADEs.
Standardization and Decreasing
Broussard et al59 implemented preprinted order sets
for pediatric sedation to improve compliance with
documentation and reduce medication errors at an
academic medical center. They conducted a retro-
spective chart review of pediatric inpatients experi-
encing procedural sedation preimplementation and
postimplementation of a preprinted packet with order
set, consent form, and form to monitor sedation.
Among 42 reviewed charts, documentation compli-
ance increased signicantly for consent and sedation
monitoring forms, physical status classication, and
allergies. Postsedation orders, medications ordered
using unit/kg, and ordering of appropriate reversal
agents also were signicantly improved. Medication
ordering errors involving sedation agents decreased
by 64% (P , .001).
Double Checks and Checklists
Lépée et al60 conducted a study to adapt the Check
and Correct checklist for use in the pediatric setting
and to measure its impact on the quality and safety of
inpatient prescribing in 2 pediatric sites. At the begin-
ning of ward rounds, a team member was designated
to review the inpatient prescription chart using the
checklist and to give immediate verbal feedback on
any shortfalls at the patient’s bedside with immediate
record correction. Data were collected on 2 types of
error: technical prescription writing errors (techni-
cal errors) and prescribing errors involving clinical
decision making (clinical errors). The most com-
mon technical error was failure to clearly document
the prescriber’s name and contact details. The most
common clinical errors were omission and wrong
dose errors. After introduction of Check and Correct,
there was a signicant drop of 5.0% in the technical
error rate, with the error rate level remaining stable
during the remaining postintervention period. There
was no change in the rate of clinical errors, since the
checklist focuses on technical aspects of prescription
Staff Education
Davey et al61 introduced a physician prescribing
tutorial and bedside prescribing routine in a pedi-
atric unit at a district general hospital in the United
Kingdom. They found that the introduction of the
tutorial decreased prescription errors by 46%. The
bedside prescribing guideline was not associated with
decreased errors, but might have helped physicians
unable to attend the tutorial.
Raja Lope et al62 studied the impact of an NICU
nurse education program including feedback, lec-
tures, and posters on compliance with medication
administration standards. Before the intervention,
50 nurses were observed administering 188 medi-
cation doses. After the intervention, 51 nurses and
169 doses were observed. There was a signicant
improvement in 7/10 standard steps in medication
administration. No adverse patient outcomes were
observed preintervention or postintervention.
Kidd et al63 evaluated the effectiveness of ongoing
training and monitoring of prescribing competency of
pediatric junior doctors in Wales from 2001 through
2007. The trainees showed signicant improvement
in a standardized assessment of prescribing compe-
tency during this period.
Gordon et al64 evaluated the effectiveness of an
inexpensive 1- to 2-hour e-learning resource on pedi-
atric prescribing on improving junior doctor prescrib-
ing skills in a randomized, controlled study. There
were no preintervention differences in prescribing
skill, habits, or condence between groups. One and
3 months after the intervention, the e-learning group
scored signicantly higher in prescribing assessment,
Neuspiel and Taylor
56 Health Services Insights 2013:6
and the e-learning group also had improved con-
dence scores at 3 months.
Chedoe et al65 studied the impact of a multifaceted
educational intervention on the rates of errors in med-
ication preparation and administration in a tertiary
NICU. The incidence of medication errors decreased
signicantly, from 49% to 31%.
Clinical Pharmacists
Folli et al66 examined the impact of clinical pharma-
cist intervention in preventing harm from medication
errors in 2 children’s hospitals. In a 6-month period,
the error rates before and after clinical pharmacist
intervention were 1.35 and 1.77 per 100 patient days,
respectively, and 4.9 and 4.5 errors per 1000 medi-
cation orders, respectively. The most common error
type was incorrect dosage, mainly overdosage. The
error rate was greatest among physicians with less
training. Clinical pharmacists’ review of drug orders
reduced the potential harm from these errors.
Krupicka et al67 looked at the impact of a clinical
pharmacist in a 10-bed pediatric critical care unit of a
children’s hospital. Costs of drug acquisition were used
to estimate cost savings. The pharmacist made 35 rec-
ommendations per 100 patient days and was assessed
to be cost-effective. However, there was no report of
impact on the prevention of medication errors.
Virani and Crown68 studied the effect of a clini-
cal pharmacist on patients and economic outcomes
in an inpatient child and adolescent psychiatric facil-
ity. During the 4-week intervention period, the phar-
macist initiated 48 interventions, 47 of which were
accepted by the treating physician; 86% of the inter-
ventions were assessed to have a positive effect on
patient care. There were 32 drug-related problems
identied, including ADEs (12), underdoses (6), drug
not indicated (6), incorrect drug (2), overdose (1),
drug indicated but not prescribed (1), and other (4).
Fernández-Llamazares69 evaluated the impact of
clinical pharmacists in reducing pediatric prescribing
errors in a maternity and children’s hospital. Among
61,458 orders in 14,713 pediatric patients, a pharma-
cist made 195 (14%) extremely or very signicant
interventions. There were 1357 errors in prescribing,
of which 833 (61%) were dosing errors, 30 (2.2%)
were potentially fatal, and 194 (14.3%) were clinically
serious. Pharmacist suggestions were accepted in
94.3% of interventions.
Improving Home Dosing Tools
Improving caregiver dosing tools is an important
strategy to reduce home medication administration
errors. Yin et al70 conducted a randomized trial test-
ing the benet of a pictographic dosing diagram to
improve parental accuracy in dosing acetaminophen
to their infants in an urban hospital clinic in New
York City. Use of pictographic dosing diagrams with
written medication instructions resulted in a 15.2%
absolute risk reduction (95% CI, 3.8–26.0) in medi-
cation administration errors compared with text-only
recipients. The benets of pictogram use were only
present among parents with low health literacy. The
same group71 had previously shown the efcacy of a
pictogram-based health literacy program in decreas-
ing medication dosing errors with liquid medication
Hixson et al72 compared a sliding card-based dos-
ing tool with product information leaets alone for
measurement and administration of acetaminophen.
The median percentage with dosing error was 0% in
the dosing card group versus 33.3% in the compari-
son group (P < .001). The group using dosing cards
had increased numbers of correct dosage intervals
and frequencies (74% to 88%, P = .046).
Culture Change and Quality
Wilson et al73 studied medication errors and ways to
prevent them in a 2-year prospective cohort study using
continuous quality improvement in an inpatient pedi-
atric cardiology center in Wales, United Kingdom. A
multidisciplinary committee analyzed reports of medi-
cation errors and proposed changes in policy and prac-
tice to reduce error frequency. During the study period,
441 medication errors were identied among 682
patients admitted for 5315 inpatient days. Errors were
7 times more frequent in the ICU setting. Physicians
were responsible for 72% of errors, and prescription
errors doubled among new doctors. Most errors (68%)
were detected before the drug was administered. Four
errors caused overt clinical consequences. There were
117 medication errors: 1 per 5.8 admissions or 1 per
45 inpatient days. In the 2nd study year, although the
incidence of total, administration, and serious errors
fell, the prescription error rate was unchanged.
Womer et al74 used rapid cycle change quality
improvement methodology to reduce chemotherapy
Reducing the risk of harm from medication errors in children
Health Services Insights 2013:6 57
errors at a children’s hospital. They achieved an 84%
reduction in chemotherapy errors that reach patients
and sustained that improvement for 5 years.
Otero et al75 studied medication errors among neo-
natal and pediatric inpatients, including the impact
of interventions to reduce errors. Samples of medi-
cation prescriptions were studied before and after a
series of interventions were implemented, including
the incorporation of a nonpunitive safety culture and
specic drug prescribing and administration recom-
mendations. Before the interventions, the medication
error rate was 11.4% compared with 7.3% after the
Bertsche et al76 assessed the impact of a quality
improvement intervention for nurses and parents on
drug administration to children by mouth or gastric
tube on a pediatric neurology ward of a university
hospital. They assessed 1164 predened drug admin-
istration tasks, 675 preintervention and 489 postinter-
vention. Errors that were addressed by the intervention
declined from 40.4% to 7.9% (P < .001) in nurses and
from 96.6% to 5.6% (P < .001) in parents. The pre-
dened errors that were reduced included tablet dis-
solution, tablet storage, oral liquids, tablet splitting,
and administration by gastric tube.
Neuspiel et al reported 2 successful quality
improvement interventions in New York77 and
Charlotte8 employing voluntary nonpunitive report-
ing of outpatient pediatric medical errors. Both sites
established multidisciplinary teams to review error
reports, conduct root-cause analyses, and imple-
ment recommendations for system changes to reduce
the likelihood of future similar errors and patient
harm. An example of an effective system change
was to reduce nurse interruptions during vaccine
Medication errors are widespread in pediatrics, in
the inpatient, outpatient, emergency department, and
home environments. Various strategies have been
tested to prevent these errors and subsequent patient
harm at the prescribing, transcribing, dispensing, and
administration phases, yet few have shown consistent
Some important efforts that have been reported or
proposed to improve pediatric medication prescribing,
transcribing, and dispensing include the following:
• E-prescribing and CPOE, particularly when cou-
pled with CCDS
• Medication reconciliation on a regular basis, espe-
cially at transitions in care
• Clinical pharmacists on inpatient units
• Education of staff and trainees
• Bar-code systems
• Standardization and checklists
• System changes to encourage teamwork and open
communication in a nonpunitive environment
Improvements to address medication administra-
tion errors include the following:
• Efforts to reduce confusion between look-alike,
sound-alike medications by changes in medication
packaging and storage
• Barcode systems to avoid patient misidenti-
• System changes to minimize nurse interruptions
• Smart infusion pumps for intravenous medica-
• Improved home dosing tools and medication labels
to reduce home medication errors
Quality improvement research involving team
approaches to error detection and system change may
help us to understand the factors contributing to pedi-
atric medication errors and generate more effective
strategies to prevent them. In addition, the automated
detection of medication errors with pediatric-specic
triggers could assist in improving our knowledge
about identifying these events and reducing patient
The magnitude of medication errors affecting infants,
children, and adolescents is just beginning to be
understood. These events affect many patients in
hospitals, medical ofces, and homes. Opportunities
to reduce patient harm must be directed to all stages
of the medication process, including packaging and
labeling, prescribing, transcribing, dispensing, and
administration in both inpatient and outpatient set-
tings. Since home medication administration is of
such great magnitude in pediatrics, involvement of
parents and other child caregivers will be critical to
reduce the harmful impact of medication errors to
Neuspiel and Taylor
58 Health Services Insights 2013:6
Author Contributions
Conceived and designed the review: DRN. Conducted
review and analyzed studies: DRN, MMT. Wrote the
rst draft of the manuscript: DRN. Contributed to the
writing of the manuscript: DRN. Agree with manu-
script results and conclusions: DRN, MMT. Jointly
developed the structure and arguments for the paper:
DRN, MMT. Made critical revisions and approved
nal version: DRN, MMT. All authors reviewed and
approved of the nal manuscript.
Author(s) disclose no funding sources.
Competing Interests
Author(s) disclose no potential conicts of interest.
Disclosures and Ethics
As a requirement of publication the authors have pro-
vided signed conrmation of their compliance with
ethical and legal obligations including but not limited
to compliance with ICMJE authorship and competing
interests guidelines, that the article is neither under
consideration for publication nor published elsewhere,
of their compliance with legal and ethical guidelines
concerning human and animal research participants
(if applicable), and that permission has been obtained
for reproduction of any copyrighted material. This
article was subject to blind, independent, expert peer
review. The reviewers reported no competing inter-
ests. Provenance: the authors were invited to submit
this paper.
1. Mohr JJ, Lannon CM, Thoma KA, et al. Learning from errors in ambulatory
pediatrics. In: Henrikson K, Battles JB, Marks ES, et al, eds. Advances in
Patient Safety: From Research to Implementation. Washington, DC: Agency
for Healthcare Research and Quality; 2005:355–368.
downloads/pub/advances/vol1/Mohr.pdf. Accessed March 2, 2013.
2. McPhillips HA, Stille CJ, Smith D, et al. Potential medication dosing errors
in outpatient pediatrics. J Pediatr. 2005;147:761–767.
3. Kaushal R, Goldmann DA, Keohane CA, et al. Adverse drug events in pedi-
atric outpatients. Ambul Pediatr. 2007;7:383–389.
4. Zandieh SO, Goldmann DA, Keohane CA, et al. Risk factors in preventable
adverse drug events in pediatric outpatients. J Pediatr. 2008;152:225–231.
5. Lemer C, Bates DW, Yoon C, et al. The role of advice in medication administra-
tion errors in the pediatric ambulatory setting. J Patient Saf. 2009;5:168–175.
6. Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paedi-
atric outpatients. Qual Saf Health Care. 2010;19:e30.
7. Condren M, Studebaker J, John BM. Prescribing errors in a pediatric clinic.
Clin Pediatr. 2010;49:49–53.
8. Neuspiel DR, Stubbs EH, Liggin L. Improving reporting of outpatient pedi-
atric medical errors. Pediatrics. 2011;128:e1608.
9. Losek JD. Acetaminophen dose accuracy and pediatric emergency care.
Pediatr Emerg Care. 2004;20:285–288.
10. Kozer E, Scolnik D, Macpherson A, et al. Variables associated with
medication errors in pediatric emergency medicine. Pediatrics. 2002;110:
11. Vilà-de-Muga M, Colom-Ferrer L, Gonzàlez-Herrero M, Luaces-Cubells C.
Factors associated with medication errors in the pediatric emergency depart-
ment. Pediatr Emerg Care. 2011;27:290–294.
12. Taylor JA, Winter L, Geyer LJ, Hawkins DS. Oral outpatient chemotherapy
medication errors in children with acute lymphoblastic leukemia. Cancer.
13. Walsh KE, Mazor KM, Stille CJ, et al. Medication errors in the homes of
children with chronic conditions. Arch Dis Child. 2011;96:581–586.
14. Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR.
Pediatric antidepressant medication errors in a national error reporting data-
base. J Dev Behav Pediatr. 2010;31:129–136.
15. Yin HS, Mendelsohn AL, Wolf MS, et al. Parents’ medication administra-
tion errors. Arch Pediatr Adolesc Med. 2010;164:181–186.
16. Sobhani P, Christopherson J, Ambrose PJ, Corelli RL. Accuracy of oral liq-
uid measuring devices: comparison of dosing cup and oral dosing syringe.
Ann Pharmacother. 2008;42:46–52.
17. Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. Evaluation of con-
sistency in dosing directionsand measuring devices for pediatric nonpre-
scription liquid medications. JAMA. 2010;304:2595–2602.
18. Wallace LS, Keenum AJ, DeVoe JE. Evaluation of consumer medical infor-
mation and oral liquid measuring devices accompanying pediatric prescrip-
tions. Acad Pediatr. 2010;10:224–227.
19. Leyva M, Sharif I, Ozuah P. Health literacy among Spanish-speaking Latino
parents with limited English prociency. Ambul Pediatr. 2005;5:56–59.
20. Sharif I, Tse J. Accuracy of computer-generated, Spanish-language medi-
cine labels. Pediatrics. 2010;125:960–965.
21. Flores G, Ngui E. Racial/ethnic disparities and patient safety. Pediatr Clin
North Am. 2006;53:1197–1215.
22. Kuo DZ, O’Connor KG, Flores G, Minkovitz CS. Pediatricians’ use of
language services for families with limited English prociency. Pediatrics.
23. Wilson KM, Singh P, Blumkin AK, Dallas L, Klein JD. Knowledge gaps
and misconceptions about over-the-counter analgesics among adolescents
attending a hospital based clinic. Acad Pediatr. 2010;10:228–232.
24. Lokker N, Sanders L, Perrin EM, et al. Parental misinterpretations of
over-the-counter pediatric cough and cold medication labels. Pediatrics.
25. Li SF, Lacher B, Crain EF. Acetaminophen and ibuprofen dosing by parents.
Pediatr Emerg Care. 2000;16:394–397.
26. McErlean MA, Barteld JM, Kennedy DA, Gilman EA, Stram RL, Raccio-
Robak N. Home antipyretic use in children brought to the emergency
department. Pediatr Emerg Care. 2001;17:249–251.
27. Goldman RD, Scolnik D. Underdosing of acetaminophen by parents and
emergency department utilization. Pediatr Emerg Care. 2004;20:89–93.
28. Chang MC, Chen YC, Chang SC, Smith GD. Knowledge of using acetamin-
ophen syrup and comprehension of written medication instruction among
caregivers with febrile children. J Clin Nursing. 2011;21:42–51.
29. Costelloe C, Montgomery AA, Redmond NM, et al. Medicine dosing by
weight in the home: Can parents accurately weight preschool children? A
method comparison study. Arch Dis Child. 2011;96:1187–1190.
30. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse
drug events in pediatric inpatients. JAMA. 2001;285:2114–2120.
31. Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for pre-
venting medication errors and adverse drug events in pediatric inpatients.
Pediatrics. 2003;111:722–729.
32. Holdsworth MT, Fichtl RE, Behta M, et al. Incidence and impact of
adverse drug events in pediatric inpatients. Arch Pediatr Adolesc Med.
33. Prot S, Fontan JE, Alberti C, et al. Drug administration errors and
their determinants in pediatric in-patients. Int J Qual Health Care.
34. Ghaleb MA, Barber N, Franklin BD, Yeung YWS. Systematic
review of medication errors in pediatric patients. Ann Pharmacother.
Reducing the risk of harm from medication errors in children
Health Services Insights 2013:6 59
35. Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten SR.
Prevention of pediatric medication errors by hospital pharmacists and
the potential benet of computerized physician order entry. Pediatrics.
36. Ferranti J, Horvath MM, Cozart H, Whitehurst J, Eckstrand J. Reevaluating
the safety prole of pediatrics: A comparison of computerized adverse drug
event surveillance and voluntary reporting in the pediatric environment.
Pediatrics. 2008;121:e1201.
37. Chua SS, Chua HM, Omar A. Drug administration errors in paediatric
wards: A direct observational approach. Eur J Pediatr. 2010;169:603–611.
38. Ghaleb MA, Barber N, Franklin BD, Wong ICK. The incidence and nature
of prescribing andmedication administration errors inpaediatric inpatients.
Arch Dis Child. 2010;95:113–118.
39. Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Safety
on an inpatient pediatric otolaryngology service: Many small errors, few
adverse events. Laryngoscope. 2009;119:871–879.
40. Al-Jeraisy MI, Alanazi MQ, Abolfotouh MA. Medication prescribing errors
in a pediatric inpatient tertiary care setting in Saudi Arabia. BMC Research
Notes. 2011;4:294.
41. Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Characteristics
of pediatric chemotherapy medication errors in a national error reporting
database. Cancer. 2007;110:186–195.
42. Alexander DC, Bundy DG, Shore AD, Morlock L, Hicks RW, Miller MR. Car-
diovascular medication errors in children. Pediatrics. 2009;124:324–332.
43. Russell RA, Murkowski K, Scanlon MC. Discrepancies between medica-
tion orders and infusion pump programming in a paediatric intensive care
unit. Qual Saf Health Care. 2010;19(suppl 3):i31–i35.
44. Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR.
NICU medication errors: Identifying a risk prole for medication errors in
the neonatal intensive care unit. J Perinatol. 2010;30:459–468.
45. Miller AD, Piro CC, Rudisill CN, Bookstaver PB, Bair JD, Bennett CL.
Nighttime and weekend medication error rates in an inpatient pediatric
population. Ann Pharmacother. 2010;44:1739–1746.
46. Miller JL, Johnson PN, Harrison DL, Hagemann TM. Evaluation of inpa-
tient admissions and potential antimicrobial and analgesic dosing errors in
overweight children. Ann Pharmacother. 2010;44:35–42.
47. Doherty C, McDonnell C. Tenfold medication errors: 5 years’ experience at
a university-afliated pediatric hospital. Pediatrics. 2012;129:916–924.
48. Kaushal R, Kern LM, Barrón Y, et al. Electronic prescribing improves
medication safety in community-based ofce practices. J Gen Intern Med.
49. van Rosse F, Maat B, Rademaker CMA, van Vught AJ, Egberts ACG,
Bollen CW. The effect of computerized physician order entry on medica-
tion prescription errors and clinical outcome in pediatric and intensive care:
A systematic review. Pediatrics 2009;123:1184–1190.
50. Stultz, JS, Nahata MC. Computerized clinical decision support for medi-
cation prescribing and utilization in pediatrics. J Am Med Inform Assoc.
51. Abramson EL, Kaushal R. Computerized provider order entry and patient
safety. Ped Clin N Am. 2012;59:1247–1255.
52. Using medication reconciliation to prevent errors. Sentinel Event Alert,
Issue 35. The Joint Commission.
errors/. Published January 25, 2006. Accessed March 3, 2013.
53. Rappaport DI, Collins B, Koster A, et al. Implementing medication recon-
ciliation in outpatient pediatrics. Pediatrics. 2011;128:e1600–e1607.
54. Stone BL, Boehme S, Mundorff MB, Maloney CG, Srivastava R. Hospi-
tal admission medication reconciliation in medically complex children: An
observational study. Arch Dis Child. 2010;95:250–255.
55. Sittig DF, Singh H. Dening health information technology-related errors.
Arch Intern Med. 2011;171:1281–1284.
56. Singh H, Classen DC, Sittig DF. Creating an oversight infrastructure for
electronic health record-related patient safety hazards. J Patient Saf.
57. Sittig DF, Singh H. Legal, ethical and nancial dilemmas in electronic
health record adoption and use. Pediatrics. 2011;127:e1042–e1047.
58. Morriss FH, Abramowitz PW, Nelson SP, et al. Effectiveness of a barcode
medication administration system in reducing preventable adverse drug
events in a neonatal intensive care unit: A Prospective cohort study.
J Pediatr. 2009;154:363–368.
59. Broussard M, Bass PF, Arnold CL, McLarty JW, Bocchini JA. Pre-
printed order sets as a safety intervention in pediatric sedation. J Pediatr.
60. Lépée C, Klaber RE, Benn J, et al. The use of a consultant-led ward round
checklist to improve paediatric prescribing: An interrupted time series study.
Eur J Pediatr. 2012;171:1239–1245.
61. Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors
in a district general hospital. Qual Saf Health Care. 2008;17:146–149.
62. Raja Lope RJ, Boo NY, Rohana J, Cheah FC. A quality assurance study on
the administration of medication by nurses in a neonatal intensive care unit.
Singapore Med J. 2009;50:68–72.
63. Kidd L, Shand E, Beavis R, Taylor Z, Dunstan F, Tuthill D. Prescrib-
ing competence of junior doctors: Does it add up? Arch Dis Child.
64. Gordon M, Chandratilake M, Baker P. Improved junior paediatric prescrib-
ing skills after a short e-learning intervention: A randomized controlled trial.
Arch Dis Child. 2011;96:1191–1194.
65. Chedoe I, Molendijk H, Hospes W, Van den Heuvel ER, Taxis K. The
effect of a multifaceted educational intervention on medication preparation
and administration errors in neonatal intensive care. Arch Dis Child Fetal
Neonatal Ed. 2012;97:F449–F455.
66. Folli HL, Poole RL, Benitz WE, Russo JC. Medication error preven-
tion by clinical pharmacists in two children’s hospitals. Pediatrics.
67. Krupicka MI, Bratton SL, Sonnenthal K, Goldstein B. Impact of a pediat-
ric clinical pharmacist in the pediatric intensive care unit. Crit Care Med.
68. Virani A, Crown N. The impact of a clinical pharmacist on patient and eco-
nomic outcomes in a child and adolescent mental health unit. Can J Hosp
Pharm. 2003;56:158–162.
69. Fernández-Llamazares CM, Calleja-Hernandez MA, Manrique-Rodriguez S,
et al. Impact of clinical pharmacist interventions in reducing paediatric pre-
scribing errors. Arch Dis Child. 2012;97:564–568.
70. Yin HS, Mendelsohn AL, Fierman A, van Schaick L, Bazan IS, Dreyer BP. Use
of a pictographic diagram to decrease parent dosing errors with infant acet-
aminophen: a health literacy perspective. Acad Pediatr. 2011;11:50–57.
71. Yin HS, Dreyer BP, van Schaick L, Foltin GL, Dinglas C, Mendelsohn AL.
Randomized controlled trial of a pictogram-based intervention to reduce
liquid medication dosing errors and improve adherence among caregivers
of young children. Arch Pediatr Adolesc Med. 2008;162:814–822.
72. Hixson R, Franke U, Mittal R, Hamilton M. Parental calculation of pediatric
paracetamol dose: a randomized trial comparing the parental analgesia slide
with product information leaets. Paediatr Anaesth. 2010;20:612–619.
73. Wilson DG, McArtney RG, Newcombe RG, et al. Medication errors in pae-
diatric practice: Insights from a continuous quality improvement approach.
Eur J Pediatr. 1998;157:769–774.
74. Womer RB, Tracy E, Soo-Hoo W, Bickert B, DiTaranto S, Barnsteiner JH.
Multidisciplinary systems approach to chemotherapy safety: Rebuilding
processes and holding the gains. J Clin Oncol. 2002;20:4705–4712.
75. Otero P, Leyton A, Mariani G, Cernadas JMC. Medication errors in pediat-
ric inpatients: Prevalence and results of a prevention program. Pediatrics.
76. Bertsche T, Bertsche A, Krieg EM, et al. Prospective pilot intervention study
to prevent medication errors in drugs administered to children by mouth
or gastric tube: a programme for nurses, physicians and parents. Qual Saf
Health Care. 2010;19:e26.
77. Neuspiel DR, Guzman M, Harewood C. Improving error reporting in ambu-
latory pediatrics with team approach. Advances in Patient Safety: New
Directions and Alternative Approaches, vol.1. Washington, DC: Agency for
Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0034-1.
78. Lemon V, Stockwell DC. Automated detection of adverse events in children.
Ped Clin N Am. 2012;59:1269–1278.
... When prescribing or dispensing medication to children, physicians and pharmacists should ensure that the medication is appropriate for the child's age or comorbidities. The different physiology, pharmacology, and pathophysiology of children compared to adults demand special requirements for pediatric medication [38,39]. Particularly in chronically ill children, who may already be suffering from restrictions owing to their specific disease, care should be taken to ensure that only appropriate medication is used. ...
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We aimed to explore parents’ perceptions of their children’s medication use for inborn errors of metabolism (IEM), including the importance of medication intake, potential complications, and concerns about adverse drug reactions (ADR). Additionally, we aimed to determine expert-assessed clinically relevant drug-related problems, particularly those attributable to IEM. We interviewed 108 parents of 119 pediatric patients with IEM using a questionnaire relating to their perceptions regarding their children’s IEM medication. In affected siblings, a questionnaire was used for each child. We performed medication analyses to evaluate the patient’s complete medication regimen for clinically relevant drug-related problems, including medication for conditions other than IEM. It was very important to the parents of 85% of the patients to use IEM medication exactly as prescribed. The parents of 41% of patients perceived complications in their children’s use of IEM medication. The parents of 47% of patients reported fears concerning ADR because of IEM medication. Parents observed ADR in 27% of patients because of IEM medication. In 44% of patients, medication for conditions other than IEM was inadequate because of drug-related problems not associated with the IEM; a safe alternative existed in 21% of patients. In summary, almost half of the parents of patients with IEM reported complications with their child’s IEM medication intake and fears of ADR. Medication analyses showed that drug-related problems occurred regardless of IEM, emphasizing the general need to prescribe and dispense adequate, child-appropriate medication to minimize clinically relevant drug-related problems in pediatric patients.
... Due to their particular physiological conditions, children are much more adversely affected by medication errors than adults [7]. Yet, studies have shown that most drug prescription and administration errors occur in pediatrics and neonatal wards (prevalence of 11% to 17%), and this becomes especially important in intensive care units for high-risk patients due to its complexities and numerous interventions [8], since twice as many drugs are administered in these departments compared to others [9]. ...
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Background prevention of medication errors in pediatric intensive care due to age and physiological condition of the patient it is very important .This study aims to identify, evaluate, and analyze potential errors in the process of drug prescription and administration in pediatric intensive care unit of Imam Reza teaching hospital in Mashhad using systematic approach of FMEA. Methods In this mixed method descriptive cross-sectional study, modes and effects of error were identified and analyzed using FMEA. This study was conducted in 10 steps. To determine potential failure modes and effects of errors team brainstorming tool is used and Factors affecting modes of error were identified using cause and effect graph (fishbone) and brainstorming method. Determined improvement strategies through interviews with team members and taking into account the requirements of the proposed risk priority number again for each of interventions were calculated. Results Identification of drug prescription and administration in intensive care unit resulted in identifying seven activities and 29 sub-processes in total drug prescription and administration processes. 68 error modes were identified of these 27 were detected as hight risk failure mode (40 ≤ RPN). Interventions that were designed to correct these errors reduced the amount of up to 50%. Conclusion FMEA showed high potentials in identifying, evaluating, prioritizing and analyzing errors in drug prescription and administration processes in pediatric intensive care unit.
... Although most studies on pediatric medication errors at home focus on dose errors [5,7], the literature has shown that parents and/or caregivers also make other mistakes, such as incorrectly preparing or reconstituting the medication [8,9] or administering the dose twice [6]. Berthe-Aucejo et al. [9] found that among parents and caregivers, risk factors for committing errors when administering medication to pediatric patients included being young, male, and non-native to their country of residence. ...
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Purpose This study aimed to identify the perceptions and attitudes of pediatricians and parents/caregivers regarding medication errors at home, and to compare the findings from the two populations. Methods This was a cross-sectional survey study. We designed a survey for working pediatricians and another one for parents or caregivers of children aged 14 years and younger. The survey’s questions were designed to assess provider and parental opinions about the difficulty faced by parents providing medical treatment, specific questions on medication errors, and on a possible intervention program aimed at preventing pediatric medication errors. Pediatrician and parent responses to matching questions in both surveys were compared. Results The surveys were administered in Spain from 2019 to 2021. In total, 182 pediatricians and 194 families took part. Most pediatricians (62.6%) and families (79.3%) considered that managing medical treatment was not among the main difficulties faced by parents in caring for their children. While 79.1% of pediatricians thought that parents consulted the internet to resolve doubts regarding the health of their children, most families (81.1%) said they consulted healthcare professionals. Lack of knowledge among parents and caregivers was one of the causes of medication errors most frequently mentioned by both pediatricians and parents. Most pediatricians (95.1%) said they would recommend a program designed to prevent errors at home. Conclusions Pediatricians and families think that medical treatment is not among the main difficulties faced by parents in caring for their children. Most pediatricians said they would recommend a medication error reporting and learning system designed for families of their patients to prevent medication errors that might occur in the home environment.
... Inappropriate drug administration in pediatric patients has become a global issue in public health. Irrational prescription and medication errors put pediatric patients at a higher risk of unwanted side effects than adults (1). In pediatrics, medication errors have a high potential for harm and are life treating in some patients (2). ...
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Background: In pediatrics, many drugs are used without marketing authorization. Recommendations are often based on clinical experience. Therefore, the risk of inappropriate prescription (IP) is high. It is necessary to have a tool for pediatric IP detection. Objectives: This study was performed to develop and validate a Pediatrics: Omission of Prescriptions and Inappropriate Prescriptions (POPI) screening tool to facilitate its use in pediatric practice in Iran. Methods: Using forward- and backward-translation procedures, an efficient and effective tool was provided in the current study and clinical settings. The two-round Delphi technique established content validity. The criteria were then piloted in a cross-sectional study in the pediatric patients of Khorasan Razavi and East Azerbaijan in Iran. Results: A total of 104 explicit criteria (79 IPs and 25 omissions) were obtained and submitted to an 18-member expert panel (including 8 pharmacists, 2 clinical pharmacists, and 8 pediatricians working in a hospital or the community). Then, 98 out of the 104 criteria submitted to the experts were selected after two Delphi rounds (75 IPs and 23 omissions). The content validity and reliability of the tool were obtained by expert assessment (Cronbach’s alpha for the entire criteria: 0.60). At least, the rate of one inappropriate prescribed medication was 69% in Mashhad, almost twice that of Tabriz (35%). Conclusions: The modified POPI criteria comprise the first screening tool to assess rational prescriptions for pediatric patients in hospital and outpatient settings. Clinical validation and reliability studies are needed and planned by the authors to evaluate the usability and reliability of this tool.
... Caring for both general PCCU patients and adults with COVID-19 housed within the same physical space has the potential to introduce latent medication safety threats. 5 Our priority was ensuring the safety and quality of care for both patient populations. Of particular concern was the risk for errors related to drug dosing differences between adults and children, such as infusions of inotropes/vasopressors, sedatives, analgesics, and antihypertensives, which are dosed by body weight in children (units/kg) as opposed to set standard doses for adults. ...
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Objectives An eight-bed adult coronavirus (COVID-19) critical care (CC) unit was established within our pediatric CC unit (PCCU) when SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) variants increased the CC bed demand. Our objective was to rapidly implement electronic order sets (OSs) to facilitate computerized provider order entry (CPOE) for adult patients admitted within a children's hospital. Methods OS development began from the assessment of OSs from seven adult CC units. Using a pre-existing PCCU admission template, we created two OSs: adult COVID-19 admission and ongoing care. We tested the prototypes in a multidisciplinary onsite–virtual hybrid tabletop simulation to evaluate usability within established workflows. Participants utilized role-specific profiles within the electronic health record (EHR) training environment which paralleled their computer interface, permitting charting and documentation. EHR analysts were present to gather change requests. Following implementation, we performed twice-daily huddles with end users to identify issues. Results A total of 13 multidisciplinary bedside providers participated in simulation testing of the prototypes. Two safety issues were addressed before implementation. The electronic OSs were developed, tested, and implemented within 8 days. The postimplementation huddles identified one medication addition, and no deletions were necessary. Conclusion Caring for adult COVID-19 patients within a freestanding children's hospital presents challenges and has the potential to introduce latent safety threats. Rapid development and implementation of electronic OSs within 8 days to facilitate CPOE and reduce health care provider cognitive burden relied on leveraging functionality within the EMR system, performing iterative testing with a tabletop simulation, integration into previously established workflows, and gathering post-implementation feedback for continuous improvement.
... 5 In clinical pediatrics, ME involves all therapeutic management phases, including prescribing, transcribing, dispensing, administering, and monitoring as the average annual ME 26.4 per 10,000 person rate in outpatients <6 years report. [7][8][9][10][11] Administering parental drugs in infants and children at home can cause several adverse events, [12][13][14][15][16] and is especially difficult when vials for adults are transformed into a liquid preparation. 17,18 Owing to parental health illiteracy, typical MEs at home include label misinterpretation and drug dosing. ...
Introduction: Whereas ample information describes medication errors (MEs) in children or in mixed pediatric and adult populations discharged with acute or chronic diseases from hospital to community settings, little is known about MEs in children and adolescents with chronic diseases discharged home, a major concern. To promote home medication safety, we trained parents of children discharged with chronic diseases to record ME with a tailored cell-phone eHealth app. Methods: In a 1-year prospective study, we used the app to monitor ME in patients with chronic diseases discharged home from a tertiary hospital in Rome, Italy. Univariate and multivariate analyses detected the ME incidence rate ratio (IRR). Results: Of the 310 parents enrolled, 194 used the app. The 41 MEs involved all drug management phases. The ME IRR was 0.46 errors per child. Children <1 year had the highest ME risk (1.69 vs. 0.35, p = 0.002). Children discharged from the cardiology unit had a statistically higher ME IRR than others (3.66, 95% confidence interval: 1.01-13.23%). Conclusions: The highest ME risk at home involves children with chronic diseases <1 year old. A significant ME IRR at home concerns children with heart diseases of any age. Parents find a tailored eHealth app for monitoring and reporting ME at home easy to use. At discharge, clinical teams need to identify age-related and disease-residual risks to target additional actions for monitoring ME, thus increasing medication safety at home.
... The real incidence of the phenomenon in the outpatient setting is however difficult to estimate and the data are generally underestimated. The main reason for the underestimation of outpatient treatment errors lies in the failure to communicate the problem that has occurred to the care provider, especially in cases where no harmful effects arise (35). ...
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Medication errors represent one of the most common causes of adverse events in pediatrics and are widely reported in the literature. Despite the awareness that children are at increased risk for medication errors, little is known about the real incidence of the phenomenon. Most studies have focused on prescription, although medication errors also include transcription, dispensing, dosage, administration, and certification errors. Known risk factors for therapeutic errors include parenteral infusions, oral fluid administration, and tablet splitting, as well as the off-label use of drugs with dosages taken from adult literature. Emergency Departments and Intensive Care Units constitute the care areas mainly affected by the phenomenon in the hospital setting. The present paper aims to identify the risk profiles in pediatric therapy to outline adequate preventive strategies. Precisely, through the analysis of the available evidence, solutions such as standardization of recommended doses for children, electronic prescribing, targeted training of healthcare professionals, and implementation of reporting systems will be indicated for the prevention of medication errors.
Acetaminophen overdose is common in the pediatric population. N-acetylcysteine (NAC) is effective at preventing liver injury in most patients when started shortly after the overdose. Delays to therapy increase risk of hepatotoxicity and liver failure that may necessitate organ transplant. Animal studies have demonstrated fomepizole may provide added benefit in acetaminophen overdose because of its ability to block the metabolic pathway that produces the toxic acetaminophen metabolite and downstream inhibition of oxidative stress pathways that lead to cell death. Several adult case reports describe use of fomepizole in patients at higher risk for poor outcomes despite NAC. We describe a case of a 7-month-old female who presented in acute liver failure with persistently elevated acetaminophen concentration secondary to repeated supratherapeutic doses of acetaminophen to manage fever. Fomepizole and NAC antidotes were used in the management of the patient. She fully recovered despite demonstrating multiple markers of poor outcome on initial presentation. Although randomized trials are lacking, this case suggests that fomepizole may safely provide additional benefit in pediatric patients at risk for severe acetaminophen toxicity.
Objectives: Children are at increased risk for medication errors and the transition from hospital-to-home is a vulnerable time for errors to occur. This study aimed to explore the perspectives of multidisciplinary clinicians and caregivers regarding discharge medication counseling and to develop a conceptual model to inform intervention efforts to reduce discharge medication dosing errors. Methods: We conducted semistructured interviews with clinicians and caregivers of children <4 years old discharged from the hospital on a liquid medication. A hierarchical coding system was developed using the interview guide and several transcripts. Qualitative analysis employed an iterative inductive-deductive approach to identify domains and subthemes and inform a conceptual framework. Results: We conducted focus groups and individual interviews with 17 caregivers and 16 clinicians. Using the Donabedian structure-process-outcomes model of quality evaluation, domains and subthemes included: (1) infrastructure of healthcare delivery, including supplies for counseling, content and organization of discharge instructions, clinician training and education, roles and responsibilities of team members, and hospital pharmacy delivery and counseling program; (2) processes of healthcare delivery, including medication reconciliation, counseling content, counseling techniques, and language barriers and health literacy; and (3) measurable outcomes, including medication dosing accuracy and caregiver understanding and adherence to discharge instructions. Conclusions: The conceptual model resulting from this analysis can be applied to the development and evaluation of interventions to reduce discharge medication dosing errors following a hospitalization. Interventions should use a health literacy universal precautions approach-written materials with plain language and pictures and verbal counseling with teach-back and show-back.
A 3-month-old infant was examined for inconsolable crying with polydipsia, polyuria, and rapid weight gain. Unexpectedly, the symptoms resolved spontaneously during hospitalization but were aggravated 2 weeks after discharge, with the patient presenting a Cushingoid appearance. Investigations ruled out diabetes mellitus and nephrogenic diabetes insipidus but indicated adrenocortical suppression by exogenous glucocorticoids, which were discovered via toxicologic analysis of her previously compounded omeprazole suspension. After discontinuing the omeprazole suspension, the infant recovered fully and the laboratory results normalized. This case shows us that the assumption of appropriate medication intake may conceal unexpected medication errors. Following this case, the current literature on the benefits and risks of compounding and its impact on patient health is discussed.
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Despite the promise of health information technology (HIT), recent literature has revealed possible safety hazards associated with its use. The Office of the National Coordinator for HIT recently sponsored an Institute of Medicine committee to synthesize evidence and experience from the field on how HIT affects patient safety. To lay the groundwork for defining, measuring, and analyzing HIT-related safety hazards, we propose that HIT-related error occurs anytime HIT is unavailable for use, malfunctions during use, is used incorrectly by someone, or when HIT interacts with another system component incorrectly, resulting in data being lost or incorrectly entered, displayed, or transmitted. These errors, or the decisions that result from them, significantly increase the risk of adverse events and patient harm. We describe how a sociotechnical approach can be used to understand the complex origins of HIT errors, which may have roots in rapidly evolving technological, professional, organizational, and policy initiatives. Arch Intern Med. 2011;171(14):1281-1284
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Context Iatrogenic injuries, including medication errors, are an important problem in all hospitalized populations. However, few epidemiological data are available regarding medication errors in the pediatric inpatient setting.Objectives To assess the rates of medication errors, adverse drug events (ADEs), and potential ADEs; to compare pediatric rates with previously reported adult rates; to analyze the major types of errors; and to evaluate the potential impact of prevention strategies.Design, Setting, and Patients Prospective cohort study of 1120 patients admitted to 2 academic institutions during 6 weeks in April and May of 1999.Main Outcome Measures Medication errors, potential ADEs, and ADEs were identified by clinical staff reports and review of medication order sheets, medication administration records, and patient charts.Results We reviewed 10 778 medication orders and found 616 medication errors (5.7%), 115 potential ADEs (1.1%), and 26 ADEs (0.24%). Of the 26 ADEs, 5 (19%) were preventable. While the preventable ADE rate was similar to that of a previous adult hospital study, the potential ADE rate was 3 times higher. The rate of potential ADEs was significantly higher in neonates in the neonatal intensive care unit. Most potential ADEs occurred at the stage of drug ordering (79%) and involved incorrect dosing (34%), anti-infective drugs (28%), and intravenous medications (54%). Physician reviewers judged that computerized physician order entry could potentially have prevented 93% and ward-based clinical pharmacists 94% of potential ADEs.Conclusions Medication errors are common in pediatric inpatient settings, and further efforts are needed to reduce them.
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Background and Objective: It has been shown that clinical pharmacists positively influence quality of care and decrease drug expenditures in hospital settings. This 2-part study was undertaken to evaluate the impact of a clinical pharmacist on patient and economic outcomes in a pediatric mental health setting. Methods: In the first part of the study, a 4-week prospective evaluation period, pharmacist-initiated interventions were documented. This information was distributed to a panel of assessors, who determined the impact of each intervention on patient care. In the second part of the study, a retrospective cost analysis was used to compare drug costs for 2 consecutive years, the 12-month period before and the 12-month period immediately after institution of the clinical pharmacy position. A matched-pair t-test and regression analysis were conducted on the cost data. Results: The pharmacist initiated 48 interventions during the 4-week period, 47 (98%) of which were accepted by the treating physician. Eighty-six percent (38/44) of the interventions were assessed as having a positive effect on patient care. Drug cost per patient-day was 14% lower in the year after implementation of the pharmacy position, and the difference was statistically significant in the last 8 months of that year (p = 0.0019). Total drug costs decreased by 21%, a cost saving of $5485.80. Conclusions: The clinical pharmacist had a positive impact on both clinical and economic outcomes in this pediatric mental health population.
Medication errors can lead to significant morbidity and mortality for patients. Children are particularly vulnerable to medication errors. A strategy for reducing medication errors and the harm resulting from these errors is use of computerized provider order entry (CPOE). This article examines the frequency and nature of prescribing errors for pediatric patients. Also discussed are the proposed benefits from CPOE use, including elimination of eligibility errors, ensuring completeness in prescribing fields, reduction in transcription errors, and improved prescribing practices through the use of clinical decision support. The literature on the effect of CPOE in actual use is explored, as are policy implications and directions for future research.
Voluntary reporting has been the standard method for identifying adverse events in hospitals, yet its effectiveness at identifying a comprehensive array of adverse events has always been in question. The electronic health record (EHR) contains clinical data that can be systematically reviewed to identify adverse events and improve adverse event detection. Active use of an automated trigger tool that is embedded in an EHR can identify systematic issues with delivery of high-risk medications and is cost-effective and efficient. Further development of an automated adverse event detection protocol for pediatrics is needed to apply this approach systematically across pediatric institutions.
Accurate and informed prescribing is essential to ensure the safe and effective use of medications in pediatric patients. Computerized clinical decision support (CCDS) functionalities have been embedded into computerized physician order entry systems with the aim of ensuring accurate and informed medication prescribing. Owing to a lack of comprehensive analysis of the existing literature, this review was undertaken to analyze the effect of CCDS implementation on medication prescribing and use in pediatrics. A literature search was performed using keywords in PubMed to identify research studies with outcomes related to the implementation of medication-related CCDS functionalities. Various CCDS functionalities have been implemented in pediatric patients leading to different results. Medication dosing calculators have decreased calculation errors. Alert-based CCDS functionalities, such as duplicate therapy and medication allergy checking, may generate excessive alerts. Medication interaction CCDS has been minimally studied in pediatrics. Medication dosing support has decreased adverse drug events, but has also been associated with high override rates. Use of medication order sets have improved guideline adherence. Guideline-based treatment recommendations generated by CCDS functionalities have had variable influence on appropriate medication use, with few studies available demonstrating improved patient outcomes due to CCDS use. Although certain medication-related CCDS functionalities have shown benefit in medication prescribing for pediatric patients, others have resulted in high override rates and inconsistent or unknown impact on patient care. Further studies analyzing the effect of individual CCDS functionalities on safe and effective prescribing and medication use are required.
Objectives: To compare the ability of parents to calculate and demonstrate the correct paracetamol (acetaminophen) dose, interval, and frequency for their child when using either product information leaflets or the Parental Analgesia Slide. Background: Prescribing information provided with over-the-counter medication may be a source of confusion for parents delivering analgesics to children at home. Accurate administration is essential to ensure safe and effective treatment of children’s pain or fever. The Parental Analgesia Slide is a new device developed with the objective of improving parental dosing accuracy. Methods: In this prospective, randomized study, 160 parents accompanying children aged between one and 13 years old were randomly allocated to complete a paracetamol dose calculation and administration questionnaire using one of two sources of prescribing information. Absolute percentage dose error and the number of correct dosage intervals, frequencies, and demonstrated drug volumes were compared. Results: Use of the Parental Analgesia Slide resulted in a reduction in the absolute percentage dose error from a median of 33.3 to 0% (P < 0.001) and an increase in the number of correct dosage intervals and frequencies (59/80 to 70/80, P = 0.046). There was no difference in the number of correctly demonstrated drug volumes (P = 0.082) despite a greater number of parents opting to use an oral syringe rather than a dosing spoon when using the Slide (24/80 to 44/80, P = 0.002). Conclusions: The Parental Analgesia Slide resulted in improved parental ability to calculate paracetamol dose, interval, and frequency while preserving their ability to demonstrate an accurate drug volume.