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Medication Safety Monday – Part 1


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Nearly ten years ago, I undertook an project for my Pharmacy degree, with the title “Minimising Medication Errors for Paediatric Inpatients”. The TGA’s recent alert about Paracetamol dosing in addition to events in the Australian national news  have lead me to consider some of the newer literature in and around the issue of inpatient medication safety in children. This post is the first in a series of five brief reviews. 


Bottom Line:

  • Children experience higher rates of medication errors than adults.
  • Most errors are made at the prescribing stage.
  • The most common kind of error is an incorrect dose.
  • Intravenous preparations are more susceptible to errors than other routes of administration.
  • Neonates are particularly susceptible to medication errors.


The cornerstone paper for the elective & literature review was Kaushal et al’s seminal 2001 JAMA study. This was a significant study in a major journal, and has shaped much of the research in this area;

Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001 Apr 25;285(16):2114-20. PMID: 11311101


1120 patients admitted to the paediatric wards at two academic hospitals (in 1999).

Intervention & comparator:

Prospective study as chart review to identify medication errors, adverse drug events, potential adverse drug events. They aimed to determine the rates, compare with adult patients (in previous studies).

Further analysis that looked at the features of errors & adverse drug events (ADEs) were potentially (or actually) occurring; specifically, the type of error, patient demographics, stage of medication, medication category and dosing route.

What was found? A higher error rate in children than in previous adult studies was identified; with an error rate of 5.7% and ADE rate of 1.1% of orders. In real numbers, that means that at least one in twenty medication orders has something go wrong.

Other findings of note include;

  • Neonates on any ward, but particularly premature neonates in the NICU were vulnerable to errors.
  • The most frequent error type was dosing errors (28%); it is noted that ten-fold over & under-doses were identified.
  • Intravenous medications & fluids were the route most susceptible to errors, accounting for more than half of errors & ADEs.

Significantly for our readership, the vast majority of errors and ADEs (74% & 79%) were at the prescribing & ordering stage. In Australia & New Zealand, this is almost solely done by doctors. Additionally, a further 10% of errors & ADEs were part of transcribing; a task done by nursing staff in the study hospitals.

One possible limitation to the study is that it was all about CPOE (computer physician order entry), that is, computer prescribing. The authors judged that 93% of the potential ADEs were potentially preventable by using computer prescribing software with decision support; and that 94% were potentially preventable with a ward-based clinical pharmacist. They highlighted the importance of decision support software, as computer medication records did not see the same high level of potential preventions.

As I’ve mentioned, this was a signpost study, and I’d recommend reading further into the paper.

*Disclosure; I work for QHealth and have worked at Royal Children’s Hospital. I’ve not worked in the PICU there, nor used the software in question.


About the authors

  • A General Paediatrician and Adolescent Medicine Fellow based in Queensland, Australia, Henry is passionate about Health Systems and Complex Care, with a strong interest in Medical Education & Clinical Teaching. His 'Dad jokes' significantly pre-date fatherhood, and he stays well by running ultramarathons. @henrygoldstein | + Henry Goldstein | Henry's DFTB posts


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