ArticleDrugs - real world outcomes2025
Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents.
Article in Drugs - real world outcomes, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers.
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Who cites it
5 citing papers in PubMed.
- How Nurses Maintain High-Risk Medication Safety in Paediatric Intensive Care.Nursing in critical care · 2026Article
- Facilitators and barriers in using barcode technology to ensure safe medication dispensing, preparation, and administration in a children's hospital: a focus group study for clinical pharmacists.International journal of clinical pharmacy · 2026Article
- Medication errors involving parenteral nutrition preparations and concentrated electrolytes in a pediatric hospital: A qualitative analysis.JPEN. Journal of parenteral and enteral nutrition · 2026Article
- Preventing Medication Errors in Paediatrics: A Narrative Review.Clinical medicine insights. Pediatrics · 2026Review
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Authors and funding
3 authors.
Funding
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Abstract
backgroundPaediatric patients are prone to medication errors, but an in-depth understanding of errors involving high-alert medications remains limited.
objectiveWe aimed to investigate incident reports involving high-alert medications to describe medication errors, error chains and stages of the medication management and use process where the errors occur in paediatric hospitals.
methodsA retrospective document analysis of self-reported medication safety incidents in a paediatric university hospital in 2018-20. The incident reports involving high-alert medications were investigated using an inductive qualitative content analysis and quantified (frequencies and percentages). A systems approach to medication risk management based on the Theory of Human Error was applied.
resultsAltogether, 560 medication errors were identified within the study sample (n = 426 incident reports). Most medication errors were associated with administration (43.1 %, n = 241/560) and prescribing (25.2 %, n = 141/560). Error chains involving two to four medication errors in one or more stages of the medication management and use process were present in 26.1% (n = 111/426) of reports, most of which originated from prescribing (62.2%; n = 69/111). The medication errors (n = 560) were classified into 14 main categories, the most common of which were wrong dose (13.9%; n = 78/560), omission of a drug (12.9%; n = 72/560) and documentation errors (10.0%; n = 56).
conclusionsPaediatric medication error chains often start from prescribing and pass through the medication management and use process. Systemic defences are especially needed for manual tasks leading to wrong doses, drug omission and documentation errors. Intravenous medications and chemotherapeutic agents, optimising drug formularies and handling, and high-alert drug use at home require further actions in paediatric medication risk management.
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Registered trials
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