Skip to main content
SpringerLink
Log in

Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis

  • Systematic Review
  • Published:
Drug Safety Aims and scope Submit manuscript

Abstract

Introduction

The risk of medication errors is high in paediatric inpatient settings. However, estimates of the prevalence of medication errors have not accounted for heterogeneity across studies in error identification methods and definitions, nor contextual differences across wards and the use of electronic or paper medication charts.

Objective

Our aim was to conduct a systematic review and meta-analysis to provide separate estimates of the prevalence of medication errors among paediatric inpatients, depending on hospital ward and the use of electronic or paper medication charts, that address differences in error identification methods and definitions.

Methods

We systematically searched five databases to identify studies published between January 2000 and December 2018 that assessed medication error rates by medication chart audit, direct observation or a combination of methods.

Results

We identified 71 studies, 19 involved paediatric wards using electronic charts. Most studies assessed prescribing errors with few studies assessing administration errors. Estimates varied by ward type. Studies of paediatric wards using electronic charts generally reported a reduced error prevalence compared to those using paper, although there were some inconsistencies. Error detection methods impacted the rate of administration errors in studies of multiple wards, however, no other difference was found. Definition of medication error did not have a consistent impact on reported error rates.

Conclusions

Medication errors are a frequent occurrence in paediatric inpatient settings, particularly in intensive care wards and emergency departments. Hospitals using electronic charts tended to have a lower rate of medication errors compared to those using paper charts. Future research employing controlled designs is needed to determine the true impact of electronic charts and other interventions on medication errors and associated harm among hospitalized children.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Pharmacovigilance Risk Assessment Committee. Good practice guide on recording, coding, reporting and assessment of medication errors. European Medicines Agency. 2015. http://www.ema.europa.eu/docs/en_GB/document_library/Regulatory_and_procedural_guideline/2015/11/WC500196979.pdf. Accessed 18 Jan 2018.

  2. The Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

    Google Scholar 

  3. World Health Organization. Reporting and learning systems for medication errors: The role of pharmacovigilance centers. 2014. http://apps.who.int/medicinedocs/documents/s21625en/s21625en.pdf. Accessed 3 Apr 2019.

  4. La Pietra L, Calligaris L, Molendini L, Quattrin R, Brusaferro S. Medical errors and clinical risk management: state of the art. Acta Otorhinolaryngol Ital. 2005;25(6):339–46.

    PubMed  PubMed Central  Google Scholar 

  5. Weingart NS, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. Br Med J. 2000;320(7237):774–7. https://doi.org/10.1136/bmj.320.7237.774.

    Article  CAS  Google Scholar 

  6. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. Br Med J. 2016;353:i2139. https://doi.org/10.1136/bmj.i2139.

    Article  Google Scholar 

  7. Aspden P, Wolcott J, Bootman L, Cronenwelt L. Prevention medication errors: quality chasm series. Washington DC: The National Academic Press; 2007.

    Google Scholar 

  8. Ghaleb MA, Barber N, Franklin BD, Yeung VWS, Khaki ZF, Wong ICK. Systematic review of medication errors in pediatric patients. Ann Pharmacother. 2006;40(10):1766–76. https://doi.org/10.1345/aph.1g717.

    Article  PubMed  Google Scholar 

  9. Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007;16(2):116–26. https://doi.org/10.1136/qshc.2006.019950.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Sharek PJ, Classen D. The incidence of adverse events and medical error in pediatrics. Pediatr Clin N Am. 2006;53(6):1067–77. https://doi.org/10.1016/j.pcl.2006.09.011.

    Article  Google Scholar 

  11. Sullivan JE, Buchino JJ. Medication errors in pediatrics—the octopus evading defeat. J Surg Oncol. 2004;88(3):182–8.

    PubMed  Google Scholar 

  12. Krzyzaniak N, Bajorek B. Medication safety in neonatal care: a review of medication errors among neonates. Ther Adv Drug Saf. 2016;7(3):102–19. https://doi.org/10.1177/2042098616642231.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dedefo MG, Mitike AH, Angamo MT. Incidence and determinants of medication errors and adverse drug events among hospitalized children in West Ethiopia. BMC Pediatr. 2016;16:81.

    PubMed  PubMed Central  Google Scholar 

  14. Santesteban E, Arenas S, Campino A. Medication errors in neonatal care: a systematic review of types of errors and effectiveness of preventive strategies. J Neonatal Nurs. 2015;21(5):200–8. https://doi.org/10.1016/j.jnn.2015.04.002.

    Article  Google Scholar 

  15. Sutcliffe K, Stokes G, O’Mara A, Caird J, Hinds K, Bangpan M, et al. Paediatric medication error: a systematic review of the extent and nature of the problem in the UK and international interventions to address it. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London; 2014. ISBN 978-1-907345-73-9.

    Google Scholar 

  16. Kaufmann J, Laschat M, Wappler F. Medication errors in pediatric emergencies: a systematic analysis. Deutsches Ärzteblatt International. 2012;109(38):609–16. https://doi.org/10.3238/arztebl.2012.0609.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kozer E, Berkovitch M, Koren G. Medication errors in children. Pediatr Clin N Am. 2006;53(6):1155–68. https://doi.org/10.1016/j.pcl.2006.09.005.

    Article  Google Scholar 

  18. Ghaleb MA, Barber N, Franklin BD, Wong ICK. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child. 2010;95(2):113–8. https://doi.org/10.1136/adc.2009.158485.

    Article  PubMed  Google Scholar 

  19. Stavroudis TA, Miller MR, Lehmann CU. Medication errors in neonates. Clin Perinatol. 2008;35(1):141–61. https://doi.org/10.1016/j.clp.2007.11.010.

    Article  PubMed  Google Scholar 

  20. Gonzales K. Medication administration errors and the pediatric population: a systematic search of the literature. J Pediatr Nurs. 2010;25(6):555–65.

    PubMed  Google Scholar 

  21. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897–903.

    PubMed  Google Scholar 

  22. Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199–205.

    CAS  PubMed  Google Scholar 

  23. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. J Am Med Assoc. 2001;285(16):2114–20.

    CAS  Google Scholar 

  24. Koumpagioti D, Varounis C, Kletsiou E, Nteli C, Matziou V. Evaluation of the medication process in pediatric patients: a meta-analysis. J Pediatr. 2014;90(4):344–55.

    Google Scholar 

  25. Meyer-Massetti C, Cheng CM, Schwappach DL, Paulsen L, Ide B, Meier CR, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm. 2011;68(3):227–40. https://doi.org/10.2146/ajhp100019.

    Article  PubMed  Google Scholar 

  26. Franklin BD, Birch S, Savage I, Wong I, Woloshynowych M, Jacklin A, et al. Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. Pharmacoepidemiol Drug Saf. 2009;18(11):992–9. https://doi.org/10.1002/pds.1811.

    Article  PubMed  Google Scholar 

  27. Westbrook JI, Li L, Lehnbom EC, Baysari MT, Braithwaite J, Burke R, et al. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care J Int Soc Qual Health Care. 2015;27(1):1–9. https://doi.org/10.1093/intqhc/mzu098.

    Article  Google Scholar 

  28. Dean Franklin B, Vincent C, Schachter M, Barber N. The incidence of prescribing errors in hospital inpatients: an overview of the research methods. Drug Saf. 2005;28(10):891–900.

    PubMed  Google Scholar 

  29. Barker KN, Flynn EA, Pepper GA. Observation method of detecting medication errors. Am J Health Syst Pharm. 2002;59(23):2314–6.

    PubMed  Google Scholar 

  30. Lisby M, Nielsen LP, Brock B, Mainz J. How are mediation errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care. 2010;22(6):507–18.

    CAS  PubMed  Google Scholar 

  31. Bates DW, Singh H. Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Aff. 2018;37(11):1736–43. https://doi.org/10.1377/hlthaff.2018.0738.

    Article  Google Scholar 

  32. Nguyen MNR, Mosel C, Grzeskowiak LE. Interventions to reduce medication errors in neonatal care: a systematic review. Ther Adv Drug Saf. 2018;9(2):123–55. https://doi.org/10.1177/2042098617748868.

    Article  PubMed  Google Scholar 

  33. Ruano M, Villamanan E, Perez E, Herrero A, Alvarez-Sala R. New technologies as a strategy to decrease medication errors: how do they affect adults and children differently? World J Pediatr WJP. 2016;12(1):28–34. https://doi.org/10.1007/s12519-015-0067-6.

    Article  CAS  PubMed  Google Scholar 

  34. Cass H. Reducing paediatric medication error through quality improvement networks; where evidence meets pragmatism. Arch Dis Child. 2016;101:414–6.

    PubMed  Google Scholar 

  35. Maaskant JM, Vermeulen H, Apampa B, Fernando B, Ghaleb MA, Neubert A, et al. Interventions for reducing medication errors in children in hospital. Cochrane Database Syst Rev. 2015;3:CD006208. https://doi.org/10.1002/14651858.cd006208.pub3.

    Article  Google Scholar 

  36. Rinke ML, Bundy DG, Velasquez CA, Rao S, Zerhouni Y, Lobner K, et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics. 2014;134(2):338–60. https://doi.org/10.1542/peds.2013-3531.

    Article  PubMed  Google Scholar 

  37. Manias E, Kinney S, Cranswick N, Williams A, Borrott N. Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother. 2014;48(10):1313–31. https://doi.org/10.1177/1060028014543795.

    Article  PubMed  Google Scholar 

  38. Walsh K, Kaushal R, Chessare J. How to avoid paediatric medication errors: a user’s guide to the literature. Arch Dis Child. 2005;90(7):698–702. https://doi.org/10.1136/adc.2003.048827.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4 Pt 1):722–9.

    PubMed  Google Scholar 

  40. Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children’s health care? Arch Pediatr Adolesc Med. 2001;155(9):1002–7.

    CAS  PubMed  Google Scholar 

  41. Wells GA, Shea B, O’Connell DP, J., Welch V, Losos M. The Newcastle–Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses. 2017. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 7 Aug 2017.

  42. Critical Appraisal Skills Programme. CASP Cohort Study Checklist. 2017. http://www.casp-uk.net/casp-tools-checklists. Accessed 5 Aug 2017.

  43. Gates PJ, Meyerson SA, Baysari MT, Lehmann CU, Westbrook JI. Preventable adverse drug events among inpatients: a systematic review. Pediatrics. 2018;142(3):e20180805.

    PubMed  Google Scholar 

  44. Gates PJ, Meyerson SA, Baysari MT, Westbrook JI. The prevalence of dose errors among paediatric patients in hospital wards with and without health information technology: a systematic review and meta-analysis. Drug Saf. 2018;42(1):13–25.

    Google Scholar 

  45. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ (Clin Res ed). 2003;327(7414):557–60.

    Google Scholar 

  46. Borenstein M, Higgins JP, Hedges LV, Rothstein HR. Basics of meta-analysis: I(2) is not an absolute measure of heterogeneity. Res Synth Methods. 2017;8(1):5–18. https://doi.org/10.1002/jrsm.1230.

    Article  PubMed  Google Scholar 

  47. Parihar M, Passi GR. Medical errors in pediatric practice. Indian Pediatr. 2008;45(7):586–9.

    PubMed  Google Scholar 

  48. Gazarian M, Graudins LV. Long-term reduction in adverse drug events: an evidence-based improvement model. Pediatrics. 2012;129(5):e1334–42. https://doi.org/10.1542/peds.2011-1902.

    Article  PubMed  Google Scholar 

  49. Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T. Computerized order entry with limited decision support to prevent prescription errors in a PICU. Pediatrics. 2009;124(3):935–40. https://doi.org/10.1542/peds.2008-2737.

    Article  PubMed  Google Scholar 

  50. Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Unit-based clinical pharmacists’ prevention of serious medication errors in pediatric inpatients. Am J Health Syst Pharm. 2008;65(13):1254–60. https://doi.org/10.2146/ajhp070522.

    Article  PubMed  Google Scholar 

  51. Kozer E, Scolnik D, Macpherson A, Keays T, Kevin Shi C, Tracy Luk C, et al. Variables associated with medication errors in pediatric emergency medicine. Pediatrics. 2002;110(4):737–42. https://doi.org/10.1542/peds.110.4.737.

    Article  PubMed  Google Scholar 

  52. Otero P, Leyton A, Mariani G, Cernadas JMC. Medication errors in pediatric inpatients: prevalence and results of a prevention program. Pediatrics. 2008;122(3):e737–43. https://doi.org/10.1542/peds.2008-0014.

    Article  PubMed  Google Scholar 

  53. Sakuma M, Ida H, Nakamura T, Ohta Y, Yamamoto K, Seki S, et al. Adverse drug events and medication errors in Japanese paediatric inpatients: a retrospective cohort study. BMJ Qual Saf. 2014;23(10):830–7.

    PubMed  Google Scholar 

  54. Sard BE, Walsh KE, Doros G, Hannon M, Moschetti W, Bauchner H. Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department. Pediatrics. 2008;122(4):782–7.

    PubMed  PubMed Central  Google Scholar 

  55. Kadmon G, Pinchover M, Weissbach A, Kogan Hazan S, Nahum E. Case not closed: prescription errors 12 years after computerized physician order entry implementation. J Pediatr. 2017;190(236–40):e2.

    Google Scholar 

  56. Campino A, Lopez-Herrera MC, Lopez-De-Heredia I, Valls-I-Soler A. Medication errors in a neonatal intensive care unit. Influence of observation on the error rate. Acta Paediatr Int J Paediatr. 2008;97(11):1591–4. https://doi.org/10.1111/j.1651-2227.2008.00982.x.

    Article  Google Scholar 

  57. Pallás CR, De-La-Cruz J, Del-Moral MT, Lora D, Malalana MA. Improving the quality of medical prescriptions in neonatal units. Neonatology. 2008;93(4):251–6. https://doi.org/10.1159/000111530.

    Article  PubMed  Google Scholar 

  58. Kunac DL, Reith DM. Preventable medication-related events in hospitalised children in New Zealand. N Zeal Med J. 2008;121(1272):17–32.

    Google Scholar 

  59. Khoo TB, Tan JW, Ng HP, Choo CM, bt Abdul Shukor INC, Teh SH. Paediatric in-patient prescribing errors in Malaysia: a cross-sectional multicentre study. Int J Clin Pharm. 2017;39(3):551–9.

    PubMed  Google Scholar 

  60. Dharmar M, Kuppermann N, Romano PS, Yang NH, Nesbitt TS, Phan J, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics. 2013;132(6):1090–7. https://doi.org/10.1542/peds.2013-1374.

    Article  PubMed  Google Scholar 

  61. Marcin JP, Dharmar M, Cho M, Seifert LL, Cook JL, Cole SL, et al. Medication errors among acutely ill and injured children treated in rural emergency departments. Ann Emerg Med. 2007;50(4):361.e2–367.e2. https://doi.org/10.1016/j.annemergmed.2007.01.020.

    Article  Google Scholar 

  62. Martinez-Anton A, Ignacio Sanchez J, Casanueva L. Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. Intensive Care Med. 2012;38(9):1532–8. https://doi.org/10.1007/s00134-012-2609-x.

    Article  PubMed  Google Scholar 

  63. Morriss FH Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN, 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(3):363.e1–368.e1. https://doi.org/10.1016/j.jpeds.2008.08.025.

    Article  Google Scholar 

  64. Prot S, Fontan JE, Alberti C, Bourdon O, Farnoux C, Macher MA, et al. Drug administration errors and their determinants in pediatric in-patients. Int J Qual Health Care J Int Soc Qual Health Care. 2005;17(5):381–9. https://doi.org/10.1093/intqhc/mzi066.

    Article  Google Scholar 

  65. Walsh KE, Landrigan CP, Adams WG, Vinci RJ, Chessare JB, Cooper MR, et al. Effect of computer order entry on prevention of serious medication errors in hospitalized children. Pediatrics. 2008;121(3):e421–7. https://doi.org/10.1542/peds.2007-0220.

    Article  PubMed  Google Scholar 

  66. Buckley MS, Erstad BL, Kopp BJ, Theodorou AA, Priestley G. Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Med. 2007;8(2):145–52.

    CAS  PubMed  Google Scholar 

  67. Machado APC, Tomich CSF, Osme SF, Ferreira DMLM, Mendonça MAO, Pinto RMC, et al. Prescribing errors in a Brazilian neonatal intensive care unit. Cadernos de Saude Publica. 2015;31(12):2610–20. https://doi.org/10.1590/0102-311x00194714.

    Article  PubMed  Google Scholar 

  68. Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten SR. Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry. Pediatrics. 2007;119(1):e77–85.

    PubMed  Google Scholar 

  69. Maaskant JM, Tio MA, van Hest RM, Vermeulen H, Geukers VGM. Medication audit and feedback by a clinical pharmacist decrease medication errors at the PICU: an interrupted time series analysis. Health Science Reports. 2018;1(3):e23.

    PubMed  PubMed Central  Google Scholar 

  70. Zeleke A, Chanie T, Woldie M. Medication prescribing errors and associated factors at the pediatric wards of Dessie Referral Hospital, Northeast Ethiopia. Int Arch Med. 2014;7(18):1–6.

    Google Scholar 

  71. Marino BL, Reinhardt K, Eichelberger WJ, Steingard R. Prevalence of errors in a pediatric hospital medication system: implications for error proofing. Outcomes Manag Nurs Pract. 2000;4(3):129–35.

    CAS  PubMed  Google Scholar 

  72. 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(6):F449–55. https://doi.org/10.1136/archdischild-2011-300989.

    Article  PubMed  Google Scholar 

  73. 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. Singap Med J. 2009;50(1):68–72.

    CAS  Google Scholar 

  74. Lalande J, Vrignaud B, Navas D, Levieux K, Herbreteau B, Guillou A, et al. A prospective observational study of medication errors in a pediatric emergency department. Arch Pediatr. 2018;25(6):355–8. https://doi.org/10.1016/j.arcped.2018.06.005.

    Article  CAS  PubMed  Google Scholar 

  75. Rinke ML, Moon M, Clark JS, Mudd S, Miller MR. Prescribing errors in a pediatric emergency department. Pediatr Emerg Care. 2008;24(1):1–8.

    PubMed  Google Scholar 

  76. Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics. 2004;113(1):59–63. https://doi.org/10.1542/peds.113.1.59.

    Article  PubMed  Google Scholar 

  77. Cimino MA, Kirschbaum MS, Brodsky L, Shaha SH. Assessing medication prescribing errors in pediatric intensive care units. Pediatr Crit Care Med. 2004;5(2):124–32. https://doi.org/10.1097/01.pcc.0000112371.26138.e8.

    Article  PubMed  Google Scholar 

  78. Ozkan S, Kocaman G, Ozturk C, Seren S. Frequency of pediatric medication administration errors and contributing factors. J Nurs Care Qual. 2011;26(2):136–43. https://doi.org/10.1097/ncq.0b013e3182031006.

    Article  PubMed  Google Scholar 

  79. Mekory TM, Bahat H, Bar-Oz B, Tal O, Berkovitch M, Kozer E. The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation. Int J Qual Health Care. 2017;29(3):366–70.

    PubMed  Google Scholar 

  80. Chua SS, Chua HM, Omar A. Drug administration errors in paediatric wards: a direct observation approach. Eur J Pediatr. 2010;169(5):603–11.

    PubMed  Google Scholar 

  81. Condren M, Honey BL, Carter SM, Ngo N, Landsaw J, Bryant C, et al. Influence of a systems-based approach to prescribing errors in a pediatric resident clinic. Acad Pediatr. 2014;14(5):485–90.

    PubMed  Google Scholar 

  82. Taylor JA, Loan LA, Kamara J, Blackburn S, Whitney D. Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. Pediatrics. 2008;121(1):123–8. https://doi.org/10.1542/peds.2007-0919.

    Article  PubMed  Google Scholar 

  83. Barber N, Franklin BD, Cornford T, Klecun E, Savage I. Safer, faster, better? Evaluating electronic prescribing: report to the patient safety research programme. London: Policy Research Programme of the Department of Health; 2006.

    Google Scholar 

  84. Benkirane RR, Abouqal R, Haimeur CC, El Kettani SS, Azzouzi AA, Mdaghri Alaoui AA, et al. Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study. J Patient Saf. 2009;5(1):16–22.

    PubMed  Google Scholar 

  85. Jain S, Basu S, Parmar V. Medication errors in neonates admitted in intensive care unit and emergency department. Indian J Med Sci. 2009;63(4):145–51. https://doi.org/10.4103/0019-5359.50763.

    Article  PubMed  Google Scholar 

  86. Kozer E, Scolnik D, MacPherson A, Rauchwerger D, Koren G. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial. Pediatrics. 2005;116(6):1299.

    PubMed  Google Scholar 

  87. Nelson CE, Selbst SM. Electronic prescription writing errors in the pediatric emergency department. Pediatr Emerg Care. 2015;31(5):368–72.

    PubMed  Google Scholar 

  88. Ozkan S, Kocaman G, Ozturk C. Effect of strategies for preventing medication administration errors in pediatric inpatients. Turk Pediatr Arsivi. 2013;48(4):299–302.

    Google Scholar 

  89. Sagy M. Optimizing patient care processes in a children’s hospital using Six Sigma. J Clin Outcomes Manag. 2009;16(9):411–4.

    Google Scholar 

  90. Taylor BL, Selbst SM, Shah AEC. Prescription writing errors in the pediatric emergency department. Pediatr Emerg Care. 2005;21(12):822–7.

    PubMed  Google Scholar 

  91. Rishoej RM, Almarsdottir AB, Thybo Christesen H, Hallas J, Juel Kjeldsen L. Identifying and assessing potential harm of medication errors and potentially unsafe medication practices in paediatric hospital settings: a field study. Ther Adv Drug Saf. 2018;9(9):509–22.

    PubMed  PubMed Central  Google Scholar 

  92. Al-Jeraisy MI, Alanazi MQ, Abolfotouh MA. Medication prescribing errors in a pediatric inpatient tertiary care setting in Saudi Arabia. BMC Res Notes. 2011;4:294. https://doi.org/10.1186/1756-0500-4-294.

    Article  PubMed  PubMed Central  Google Scholar 

  93. Ewig CLY, Cheung HM, Kam KH, Wong HL, Knoderer CA. Occurrence of potential adverse drug events from prescribing errors in a pediatric intensive and high dependency unit in Hong Kong: an observational study. Pediatric Drugs. 2017;19(4):347–55.

    PubMed  Google Scholar 

  94. Glanzmann C, Frey B, Meier CR, Vonbach P. Analysis of medication prescribing errors in critically ill children. Eur J Pediatr. 2015;174(10):1347–55. https://doi.org/10.1007/s00431-015-2542-4.

    Article  PubMed  Google Scholar 

  95. Gokhul A, Jeena PM, Gray A. Iatrogenic medication errors in a paediatric intensive care unit in Durban, South Africa. S Afr Med J. 2016;106(12):1222–9.

    CAS  PubMed  Google Scholar 

  96. Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children’s hospital. Pediatrics. 2006;118(4):e1124–9. https://doi.org/10.1542/peds.2005-3183.

    Article  PubMed  Google Scholar 

  97. Chua SS, Choo SM, Sulaiman CZ, Omar A, Thong MK. Effects of sharing information on drug administration errors in pediatric wards: a pre-post intervention study. Ther Clin Risk Manag. 2017;13:345–53.

    PubMed  PubMed Central  Google Scholar 

  98. Alagha HZ, Badary OA, Ibrahim HM, Sabri NA. Reducing prescribing errors in the paediatric intensive care unit: an experience from Egypt. Acta Paediatr. 2011;100(10):e169–74.

    PubMed  Google Scholar 

  99. Alsulami Z, Choonara I, Conroy S. Paediatric nurses’ adherence to the double-checking process during medication administration in a children’s hospital: an observational study. J Adv Nurs. 2014;70(6):1404–13. https://doi.org/10.1111/jan.12303.

    Article  PubMed  Google Scholar 

  100. Booth R, Sturgess E, Taberner-Stokes A, Peters M. Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit. Intensive Care Med. 2012;38(11):1858–67.

    PubMed  Google Scholar 

  101. Davey AL, Britland A, Naylor RJ. Decreasing paediatric prescribing errors in a district general hospital. Qual Saf Health Care. 2008;17(2):146–9. https://doi.org/10.1136/qshc.2006.021212.

    Article  CAS  PubMed  Google Scholar 

  102. Eisenhut M, Sun B, Skinner S. Reducing prescribing errors in paediatric patients by assessment and feedback targeted at prescribers. ISRN Pediatr. 2011. https://doi.org/10.5402/2011/545681.

    Article  PubMed  PubMed Central  Google Scholar 

  103. Feleke Y, Girma B. Medication administration errors involving paediatric in-patients in a hospital in Ethiopia. Trop J Pharm Res. 2010;9(4):401–7.

    Google Scholar 

  104. Jozefczyk KG, Kennedy WK, Lin MJ, Achatz J, Glass MD, Eidam WS, et al. Computerized prescriber order entry and opportunities for medication errors: comparison to tradition paper-based order entry. J Pharm Pract. 2013;26(4):434–7. https://doi.org/10.1177/0897190012465982.

    Article  PubMed  Google Scholar 

  105. Khaemba CN. Incidence and determinants of medication errors among paediatric in-patients at Kisii level 5 hospital. Nairobi: University of Nairobi; 2014.

    Google Scholar 

  106. Lepee C, Klaber RE, Benn J, Fletcher PJ, Cortoos PJ, Jacklin A, 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(8):1239–45. https://doi.org/10.1007/s00431-012-1751-3.

    Article  PubMed  Google Scholar 

  107. Nikhithasri P, Ramya M, Kishore P. Assessment of medication errors in pediatric inpatient department of a private hospital. Int J Curr Pharm Res. 2017;9(6):70–5.

    Google Scholar 

  108. Palmero D, Di Paolo ER, Beauport L, Pannatier A, Tolsa JF. A bundle with a preformatted medical order sheet and an introductory course to reduce prescription errors in neonates. Eur J Pediatr. 2016;175(1):113–9. https://doi.org/10.1007/s00431-015-2607-4.

    Article  PubMed  Google Scholar 

  109. Rashed AN, Neubert A, Tomlin S, Jackman J, Alhamdan H, AlShaikh A, et al. Epidemiology and potential associated risk factors of drug-related problems in hospitalised children in the United Kingdom and Saudi Arabia. Eur J Clin Pharmacol. 2012;68(12):1657–66.

    PubMed  Google Scholar 

  110. Rashed AN, Wilton L, Lo CCH, Kwong BYS, Leung S, Wong ICK. Epidemiology and potential risk factors of drug-related problems in Hong Kong paediatric wards. Br J Clin Pharmacol. 2014;77(5):873–9. https://doi.org/10.1111/bcp.12270.

    Article  PubMed  PubMed Central  Google Scholar 

  111. Warrick C, Naik H, Avis S, Fletcher P, Franklin BD, Inwald D. A clinical information system reduces medication errors in paediatric intensive care. Intensive Care Med. 2011;37(4):691–4.

    PubMed  Google Scholar 

  112. Truter A, Schellack N, Meyer JC. Identifying medication errors in the neonatal intensive care unit and paediatric wards using a medication error checklist at a tertiary academic hospital in Gauteng, South Africa. SAJCH S Afr J Child Health. 2017;11(1):5–10.

    Google Scholar 

  113. Baraki Z, Abay M, Tsegay L, Gerensea H, Kebede A, Teklay H. Medication administration error and contributing factors among pediatric inpatient in public hospitals of Tigray, northern Ethiopia. BMC Pediatr. 2018;18(1):321.

    PubMed  PubMed Central  Google Scholar 

  114. Abuelsoud N. Pharmacy quality improvement project to enhance the medication management process in pediatric patients. Ir J Med Sci. 2018. https://doi.org/10.1007/s11845-018-1860-8.

    Article  PubMed  Google Scholar 

  115. American Society of Healthsystem Pharmacists. ASHP standard definition of a medication error. Am J Hosp Pharm. 1982;39(2):321.

    Google Scholar 

  116. Benkirane R, Abouqal R, Haimeur C, El Kettani S, Azzouzi A, Mdaghri Alaoui A, et al. Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study. J Patient Saf. 2009;5(1):16–22.

    PubMed  Google Scholar 

  117. Campino A, Lopez-Herrera MC, Lopez-De-Heredia I, Valls-I-Soler A. Educational strategy to reduce medication errors in a neonatal intensive care unit. Acta Paediatr Int J Paediatr. 2009;98(5):782–5. https://doi.org/10.1111/j.1651-2227.2009.01234.x.

    Article  Google Scholar 

  118. Nakamura MM, Harper MB, Jha AK. Change in adoption of electronic health records by US children’s hospitals. Pediatrics. 2013;131(5):e1563–75. https://doi.org/10.1542/peds.2012-2904.

    Article  PubMed  Google Scholar 

  119. Lehmann CU. Council on clinical information technology. Pediatric aspects of inpatient health information technology systems. Pediatrics. 2015;135(3):e756–68. https://doi.org/10.1542/peds.2014-4148.

    Article  PubMed  Google Scholar 

  120. Chedoe I, Molendijk HA, Dittrich STAM, Jansman FGA, Harting JW, Brouwers JRBJ, et al. Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety: a review of the current literature. Drug Saf. 2007;30(6):503–13. https://doi.org/10.2165/00002018-200730060-00004.

    Article  PubMed  Google Scholar 

  121. Rogers AE, Hwang W-T, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff. 2004;23(4):202–12. https://doi.org/10.1377/hlthaff.23.4.202.

    Article  Google Scholar 

  122. Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet. 2000;356(9225):185–9. https://doi.org/10.1016/S0140-6736(00)02478-8.

    Article  CAS  PubMed  Google Scholar 

  123. Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf. 2011;20(12):1027–34. https://doi.org/10.1136/bmjqs-2011-000089.

    Article  PubMed  PubMed Central  Google Scholar 

  124. Walsh KE, Harik P, Mazor KM, Perfetto D, Anatchkova M, Biggins C, et al. Measuring harm in health care: optimizing adverse event review. Med Care. 2017;55(4):436–41.

    PubMed  PubMed Central  Google Scholar 

  125. Hayes C, Jackson D, Davidson PM, Power T. Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. J Clin Nurs. 2015;24(21–22):3063–76. https://doi.org/10.1111/jocn.12944.

    Article  PubMed  Google Scholar 

  126. Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study. BMJ Qual Saf. 2017;26(9):734–42. https://doi.org/10.1136/bmjqs-2016-006123.

    Article  PubMed  PubMed Central  Google Scholar 

  127. Dean B, Barber N. Validity and reliability of observational methods for studying medication administration errors. Am J Health Syst Pharm. 2001;58(1):54–9.

    CAS  PubMed  Google Scholar 

  128. Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116(6):1506–12. https://doi.org/10.1542/peds.2005-1287.

    Article  PubMed  Google Scholar 

  129. Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, Lo C, et al. Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. PLoS Med. 2012;9(1):e1001164. https://doi.org/10.1371/journal.pmed.1001164.

    Article  PubMed  PubMed Central  Google Scholar 

  130. Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review. J Am Med Inform Assoc JAMIA. 2009;16(5):613–23. https://doi.org/10.1197/jamia.m3050.

    Article  PubMed  Google Scholar 

  131. Lapkin S, Levett-Jones T, Chenoweth L, Johnson M. The effectiveness of interventions designed to reduce medication administration errors: a synthesis of findings from systematic reviews. J Nurs Manag. 2016;24(7):845–58. https://doi.org/10.1111/jonm.12390.

    Article  PubMed  Google Scholar 

  132. Bannan DF, Tully MP. Bundle interventions used to reduce prescribing and administration errors in hospitalized children: a systematic review. J Clin Pharm Therap. 2016. https://doi.org/10.1111/jcpt.12398.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia

    Peter J. Gates, Magdalena Z. Raban, Sophie Meyerson & Johanna I. Westbrook

  2. Faculty of Health Sciences, The University of Sydney, Sydney, Australia

    Melissa T. Baysari

  3. School of Medical Sciences, Faculty of Medicine, University of NSW Sydney, Sydney, Australia

    Madlen Gazarian

Authors
  1. Peter J. Gates
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Melissa T. Baysari
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Madlen Gazarian
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Magdalena Z. Raban
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sophie Meyerson
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Johanna I. Westbrook
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter J. Gates.

Ethics declarations

Conflict of interest

Peter Gates, Melissa Baysari, Madlen Gazarian, Magdalena Raban, Sophie Meyerson, and Johanna Westbrook have no conflicts of interest that are directly relevant to the content of this study.

Funding

Funding from a National Health and Medical Research Council Partnership Grant (APP1094878) was used to assist with this research. MZR is supported by a National Health and Medical Research Council Early Career Fellowship (APP1143941).

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gates, P.J., Baysari, M.T., Gazarian, M. et al. Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis. Drug Saf 42, 1329–1342 (2019). https://doi.org/10.1007/s40264-019-00850-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40264-019-00850-1

Search

Navigation