Paeds · professional-practice-and-evidence
Medication safety and error prevention in children
Also known as Paediatric medication errors · Adverse drug events in children · Tenfold dosing errors · Safe paediatric prescribing · Medication Without Harm children
Fellowship guide to medication safety and error prevention in children: the medication-use process, why children are vulnerable, error classification and harm severity, the Swiss-cheese mechanism, high-risk drugs, tenfold dosing errors, and the layered prevention and response system.
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Target exams
Red flags
- Suspected tenfold opioid, insulin or electrolyte overdose in a neonate or infant
- Child deteriorating after a new infusion or dose change
- Wrong drug, wrong route or wrong-rate infusion still running
- Look-alike sound-alike drug still in the dispensing stock or on the ward
- Other children exposed to the same erroneous protocol or pump setting
- Medication error discovered but not escalated, reported or disclosed
- Repeated similar near misses with no system action
Life stages
Care settings
Clinical exam formats
Board mappings
- Professional qualities and patient safety
- Quality and safety of clinical care
- Pharmacology and safe prescribing
- Learning goal: safe prescribing and medication safety in general paediatrics
- Quality improvement and patient safety
- Professional practice and ethics
- Professional Qualities
- Clinical Applications and safe prescribing
- Long Cases involving a child with polypharmacy or a medication incident
- Short Cases on high-risk medication safety
- Communication stations on disclosure of a medication error
- Patient safety and quality improvement
- Safe prescribing and medication safety
- Leadership and team working
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Communication
- History taking and management
- Patient safety station
- General Pediatrics Content Outline — patient safety and quality improvement
- General Pediatrics Content Outline — pharmacology and safe prescribing
- Systems-based practice and quality improvement
- Systems-Based Practice 1: Patient Safety and Quality Improvement
- Patient Care: safe prescribing and medication safety
- Practice-Based Learning and Improvement: analysing a medication incident
- Interpersonal and Communication Skills: disclosure of error
- Medical Expert
- Collaborator
- Health Advocate
- Pediatric EPA — safe prescribing and medication safety
Overview & Definition
A registrar writes an opioid infusion for a six-month-old. The pump is set ten times too fast. The nurse notices the baby is dusky and stops it. Your first job is clinical rescue. Your second job is to understand medication safety and error prevention in children so the next infant is protected. This leaf owns that pathway; the broader human-factors and incident-reporting theory lives on the adverse-events page. [1] [13]
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the drug is in the control of a clinician, patient or carer. An adverse drug event (ADE) is actual injury caused by a medication — not every error causes an ADE, and not every ADE starts with an error. An adverse drug reaction is an intrinsic, often non-preventable pharmacological response. A near miss is an error caught before it reaches the child. Holding these four ideas apart is half the viva. [1] [2]
References15ShowHide
- [1]Kaushal R Medication errors and adverse drug events in pediatric inpatients. JAMA, 2001.PMID 11311101
- [2]Leape LL Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA, 1995.PMID 7791256
- [3]Fortescue EB Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics, 2003.PMID 12671103
- [4]Stucky ER Prevention of medication errors in the pediatric inpatient setting. Pediatrics, 2003.PMID 12897304
- [5]Miller MR Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Quality and safety in health care, 2007.PMID 17403758
- [6]Ghaleb MA The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Archives of disease in childhood, 2010.PMID 20133327
- [7]Potts AL Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics, 2004.PMID 14702449
- [8]Kozer E The effect of detection approaches on the reported incidence of tenfold errors. Drug safety, 2006.PMID 16454544
- [9]Kozer E The effect of a short tutorial on the incidence of prescribing errors in pediatric emergency care. Canadian journal of clinical pharmacology, 2006.PMID 17085777
- [10]Bonafide CP Association Between Mobile Telephone Interruptions and Medication Administration Errors in a Pediatric Intensive Care Unit. JAMA pediatrics, 2020.PMID 31860017
- [11]Jani YH Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic. The Journal of pediatrics, 2008.PMID 18206691
- [12]Ameer A Systematic literature review of hospital medication administration errors in children. Integrated pharmacy research & practice, 2015.PMID 29354530
- [13]Reason J Human error: models and management. The Western journal of medicine, 2000.PMID 10854390
- [14]Konwinski L Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach. Journal of patient safety, 2024.PMID 38231892
- [15]Jani YH Characteristics of clinical decision support alert overrides in an electronic prescribing system at a tertiary care paediatric hospital. International journal of pharmacy practice, 2011.PMID 21899617