Medication Errors in Children

Pediatric Clinics of North America

Volumn 53, Issue 6, 2006, Pages 1155-1168

  Kozer, Eran ^a,b   Berkovitch, Matitiahu ^a,b   Koren, Gideon ^c,d  

^a ASSAF HAROFEH MEDICAL CENTER   (Israel)

^b TEL AVIV UNIVERSITY   (Israel)

^c HOSPITAL FOR SICK CHILDREN   (Canada)

^d UNIVERSITY OF TORONTO   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

CODEINE; NALOXONE; PENICILLIN G;

ALLERGIC REACTION; AMBULATORY CARE; APNEA; COMPUTER PROGRAM; EMERGENCY WARD; FATIGUE; HEALTH CARE; HEALTH PRACTITIONER; HUMAN; IATROGENIC DISEASE; INTENSIVE CARE UNIT; MEDICATION ERROR; PATIENT SAFETY; PHARMACY; PHYSICIAN; PRESCRIPTION; REVIEW; RISK ASSESSMENT; TEAMWORK;

CHILD; DECISION SUPPORT SYSTEMS, CLINICAL; FEMALE; HUMANS; MEDICAL ORDER ENTRY SYSTEMS; MEDICATION ERRORS; RISK FACTORS;

EID: 33751169563     PISSN: 00313955     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.pcl.2006.09.005     Document Type: Review

References (72)

1. Kohn L.T., Corrigan J.M., and Donaldson M.S. To err is human: building a safer health system (2000), National Academy Press, Washington, DC
2. Bates D.W., Cullen D.J., Laird N., et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 274 1 (1995) 29-34
3. Leape L.L., Brennan T.A., Laird N., et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324 6 (1991) 377-384
4. Brennan T.A., Leape L.L., Laird N.M., et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324 6 (1991) 370-376
5. Buehler J.W., Smith L.F., Wallace E.M., et al. Unexplained deaths in a children's hospital. An epidemiologic assessment. N Engl J Med 313 4 (1985) 211-216
6. Koren G., Barzilay Z., and Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic disease in pediatrics. Pediatrics 77 6 (1986) 848-849
7. Phillips D.P., Christenfeld N., and Glynn L.M. Increase in US medication-error deaths between 1983 and 1993. Lancet 351 9103 (1998) 643-644
8. Bates D.W., Spell N., Cullen D.J., et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 277 4 (1997) 307-311
9. Lesar T.S., Briceland L.L., Delcoure K., et al. Medication prescribing errors in a teaching hospital. JAMA 263 17 (1990) 2329-2334
10. Lesar T.S. Errors in the use of medication dosage equations. Arch Pediatr Adolesc Med 152 4 (1998) 340-344
11. Conroy S., Choonara I., Impicciatore P., et al. Survey of unlicensed and off label drug use in paediatric wards in European countries. European Network for Drug Investigation in Children. BMJ 320 7227 (2000) 79-82
12. Yu K.H., Nation R.L., and Dooley M.J. Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough?. Qual Saf Health Care 14 5 (2005) 358-363
13. Ghaleb M.A., Barber N., Dean F.B., et al. What constitutes a prescribing error in paediatrics?. Qual Saf Health Care 14 5 (2005) 352-357
14. Wilson D.G., McArtney R.G., Newcombe R.G., et al. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr 157 9 (1998) 769-774
15. Lesar T.S., Briceland L., and Stein D.S. Factors related to errors in medication prescribing. JAMA 277 4 (1997) 312-317
16. Wong I.C., Ghaleb M.A., Franklin B.D., et al. Incidence and nature of dosing errors in paediatric medications: a systematic review. Drug Saf 27 9 (2004) 661-670
17. Kaushal R., Bates D.W., Landrigan C., et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 285 16 (2001) 2114-2120
18. Kozer E., Scolnik D., Macpherson A., et al. Variables associated with medication errors in pediatric emergency medicine. Pediatrics 110 4 (2002) 737-742
19. Selbst S.M., Fein J.A., Osterhoudt K., et al. Medication errors in a pediatric emergency department. Pediatr Emerg Care 15 1 (1999) 1-4
20. Vincer M.J., Murray J.M., Yuill A., et al. Drug errors and incidents in a neonatal intensive care unit. A quality assurance activity. Am J Dis Child 143 6 (1989) 737-740
21. Folli H.L., Poole R.L., Benitz W.E., et al. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 79 5 (1987) 718-722
22. Perlstein P.H., Callison C., White M., et al. Errors in drug computations during newborn intensive care. Am J Dis Child 133 4 (1979) 376-379
23. Glover M.L., and Sussmane J.B. Assessing pediatrics residents' mathematical skills for prescribing medication: a need for improved training. Acad Med 77 10 (2002) 1007-1010
24. Rowe C., Koren T., and Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child 79 1 (1998) 56-58
25. Kozer E., Scolnik D., Keays T., et al. Large errors in the dosing of medications for children. N Engl J Med 346 15 (2002) 1175-1176
26. Lesar T.S. Tenfold medication dose prescribing errors. Ann Pharmacother 36 12 (2002) 1833-1839
27. Ross L.M., Wallace J., and Paton J.Y. Medication errors in a paediatric teaching hospital in the UK: five years' operational experience. Arch Dis Child 83 6 (2000) 492-497
28. Kozer E., Scolnik D., Jarvis A.D., and Koren G. The effect of detection approaches on the reported incidence of tenfold errors. Drug Saf 29 2 (2006) 169-174
29. Bordun L.A., and Butt W. Drug errors in intensive care. J Paediatr Child Health 28 4 (1992) 309-311
30. Raju T.N., Kecskes S., Thornton J.P., et al. Medication errors in neonatal and paediatric intensive-care units. Lancet 2 8659 (1989) 374-376
31. Kozer E., Seto W., Verjee Z., et al. Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. BMJ 329 7478 (2004) 1321
32. Heubi J.E., Barbacci M.B., and Zimmerman H.J. Therapeutic misadventures with acetaminophen: hepatoxicity after multiple doses in children. J Pediatr 132 1 (1998) 22-27
33. Goldman R.D., and Scolnik D. Underdosing of acetaminophen by parents and emergency department utilization. Pediatr Emerg Care 20 2 (2004) 89-93
34. Simon H.K., and Weinkle D.A. Over-the-counter medications. Do parents give what they intend to give?. Arch Pediatr Adolesc Med 151 7 (1997) 654-656
35. Simon H.K. Caregiver knowledge and delivery of a commonly prescribed medication (albuterol) for children. Arch Pediatr Adolesc Med 153 6 (1999) 615-618
36. Greenberg R., Grossman Z., Goldstein L., et al. How much acetaminophen do paediatricians prescribe? A survey among Israeli paediatricians. J Clin Pharm Ther 30 5 (2005) 443-446
37. Watson W.A., Litovitz T.L., Rodgers Jr. G.C., et al. 2004 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 23 5 (2005) 589-666
38. Leape L.L., Bates D.W., Cullen D.J., et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA 274 1 (1995) 35-43
39. West D.W., Levine S., Magram G., et al. Pediatric medication order error rates related to the mode of order transmission. Arch Pediatr Adolesc Med 148 12 (1994) 1322-1326
40. Sexton J.B., Thomas E.J., and Helmreich R.L. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 320 7237 (2000) 745-749
41. Landrigan C.P., Rothschild J.M., Cronin J.W., et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 351 18 (2004) 1838-1848
42. Lockley S.W., Cronin J.W., Evans E.E., et al. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med 351 18 (2004) 1829-1837
43. Pickup J. Cause of dosing errors. Lancet 362 (2003) 252
44. Stucky E.R. Prevention of medication errors in the pediatric inpatient setting. Pediatrics 112 2 (2003) 431-436
45. Bates D.W., Leape L.L., Cullen D.J., et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 280 15 (1998) 1311-1316
46. Fontan J.E., Maneglier V., Nguyen V.X., et al. Medication errors in hospitals: computerized unit dose drug dispensing system versus ward stock distribution system. Pharm World Sci 25 3 (2003) 112-117
47. King W.J., Paice N., Rangrej J., et al. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics 112 3 Pt 1 (2003) 506-509
48. Potts A.L., Barr F.E., Gregory D.F., et al. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 113 1 Pt 1 (2004) 59-63
49. Koppel R., Metlay J.P., Cohen A., et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 293 10 (2005) 1197-1203
50. Longo D.R., Hewett J.E., Ge B., et al. The long road to patient safety: a status report on patient safety systems. JAMA 294 22 (2005) 2858-2865
51. Ash J.S., Gorman P.N., Seshadri V., et al. Computerized physician order entry in US hospitals: results of a 2002 survey. J Am Med Inform Assoc 11 2 (2004) 95-99
52. Kirk R.C., Li-Meng G.D., Packia J., et al. Computer calculated dose in paediatric prescribing. Drug Saf 28 9 (2005) 817-824
53. Weingart S.N., Toth M., Sands D.Z., et al. Physicians' decisions to override computerized drug alerts in primary care. Arch Intern Med 163 21 (2003) 2625-2631
54. Kozer E., Scolnik D., Macpherson A., et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized controlled trial. Pediatrics 116 6 (2005) 1299-1302
55. Shah A.N., Frush K., Luo X., et al. Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events. Arch Pediatr Adolesc Med 157 3 (2003) 229-236
56. Frush K.S., Luo X., Hutchinson P., et al. Evaluation of a method to reduce over-the-counter medication dosing error. Arch Pediatr Adolesc Med 158 7 (2004) 620-624
57. Leape L.L., Cullen D.J., Clapp M.D., et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 282 3 (1999) 267-270
58. Bond C.A., Raehl C.L., and Franke T. Medication errors in United States hospitals. Pharmacotherapy 21 9 (2001) 1023-1036
59. Tisdale J.E. Justifying a pediatric critical-care satellite pharmacy by medication-error reporting. Am J Hosp Pharm 43 2 (1986) 368-371
60. Shaughnessy A.F., and D'Amico F. Long-term experience with a program to improve prescription-writing skills. Fam Med 26 3 (1994) 168-171
61. Bayne T., and Bindler R. Effectiveness of medication calculation enhancement methods with nurses. J Nurs Staff Dev 13 6 (1997) 293-301
62. Dean B., Schachter M., Vincent C., et al. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 359 9315 (2002) 1373-1378
63. Fortescue E.B., Kaushal R., Landrigan C.P., et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 111 4 Pt 1 (2003) 722-729
64. Borel J.M., and Rascati K.L. Effect of an automated, nursing unit-based drug-dispensing device on medication errors. Am J Health Syst Pharm 52 (1995) 1875-1879
65. Wright A.A., and Katz I.T. Bar coding for patient safety. N Engl J Med 353 (2005) 329-331
66. Oren E., Shaffer E.R., and Guglielmo B.J. Impact of emerging technologies on medication errors and adverse drug events. Am J Health Syst Pharm 60 (2003) 1447-1458
67. O'Neil A.C., Petersen L.A., Cook E.F., et al. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med 119 5 (1993) 370-376
68. Frey B., Buettiker V., Hug M.I., et al. Does critical incident reporting contribute to medication error prevention?. Eur J Pediatr 161 11 (2002) 594-599
69. Suresh G., Horbar J.D., Plsek P., et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 113 6 (2004) 1609-1618
70. Cullen D.J., Bates D.W., Small S.D., et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 21 10 (1995) 541-548
71. Flynn E.A., Barker K.N., Pepper G.A., et al. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 59 5 (2002) 436-446
72. Parshuram C.S., Ng G.Y., Ho T.K., et al. Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Crit Care Med 31 10 (2003) 2483-2487