Reducing the Risk of Harm From Medication Errors in Children

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 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.

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Health Services Insights 2013:6 47–59
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Health Services Insights
REVIEW
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: daniel.neuspiel@carolinashealthcare.org
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
Background
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.
Methods
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
Pediatrics
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
illegibility.6
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
hazardous.
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
administrations.
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
hospitals.
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.
E-prescribing
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
studied.
• 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
reduction.
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
outcomes.
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
documentation.
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
Ambiguity
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
writing.
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
prescriptions.
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
Improvement
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
interventions.
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
preparation.
Discussion
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
effectiveness.
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-
cation
• System changes to minimize nurse interruptions
• Smart infusion pumps for intravenous medica-
tions
• 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
harm.78
Conclusion
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
children.

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.
Funding
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.
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