Published online September 1, 2008
PEDIATRICS Vol. 122 No. 3 September 2008, pp. e737-e743 (doi:10.1542/peds.2008-0014)

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Otero, P. Search for Related Content PubMed PubMed Citation Articles by Otero, P. Related Collections Office Practice Social Bookmarking                         What's this?

REVIEW ARTICLE

Medication Errors in Pediatric Inpatients: Prevalence and Results of a Prevention Program

Paula Otero, MD, Andrea Leyton, RN, Gonzalo Mariani, MD, José María Ceriani Cernadas, MD and the Patient Safety Committee

Department of Pediatrics, School of Medicine Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 
OBJECTIVE. The objective of this study was to assess the prevalence and characteristics of medication errors in pediatric and neonatal inpatients and to measure the impact of interventions to reduce medication errors.

METHODS. A preintervention and postintervention cross-sectional study was conducted of a sample of prescriptions that were ordered by physicians and medications that were administered by nurses to patients at the NICU, PICU, and general pediatric settings at the Hospital Italiano de Buenos Aires Department of Pediatrics in 2002 and 2004. Number and type of errors, time shift on which they occurred, and whether they had any kind of adverse event on the patient were recorded. Medication errors were stratified according to physicians' and nurses' status. Several interventions, including incorporating a positive safety culture without a punitive management of errors and specific prescribing and drug-administration recommendations were implemented between the 2 phases of the study.

RESULTS. A total of 590 prescriptions and 1174 drug administrations for 95 patients in the first phase of the study and 1144 prescriptions with 1588 drug administrations for 92 patients in the second phase were evaluated. The prevalence of medication error rate in the second phase was 7.3% (199 of 2732) and 11.4% (201 of 1764) in the first phase. The risk difference was –4.1%.

CONCLUSIONS. The development of a program mainly centered on the promotion of a cultural change in the approach to medical errors can effectively diminish medication errors in neonates and children.

---

Key Words: medication errors • prevalence • prevention • child • newborn

Abbreviations: GPW—general pediatrics ward • OR—odds ratio • CI—confidence interval

Errors are frequent in medical practice as a result of its human nature and of the complexity of medical management. According to the Greeks, the main commitment of physicians is to avoid patient harm (primum non nocere, or "first, do no harm"). In modern medicine, errors are still frequent.^1–3 Some do not have severe consequences, but others produce important injuries and, in some cases, even death. Attitudes toward these events include hiding the errors or even punishing the person who made the mistake. These approaches neither allow the physician to recognize the error nor stimulate the search for the cause, making it difficult to generate a more safety-oriented attitude among health care professionals.^{4, 5} Publications on this subject have increased in the past few years.⁶

Errors in medication use constitute the most frequent medical error. In a study conducted at Harvard University¹ (a seminal article on this subject), medication errors were the most common cause of iatrogenic adverse events (19.4%). Other studies also identified the high frequency of medication errors. Their results vary widely (1.5%–35%), depending on many factors, such as type of classification and method to identify the errors.^7–12 Although the frequency is similar for children and adults, the risks for errors with potential for harm are 3 times as high for children.¹³ Medication errors that result in patient harm also increase the costs of medical care.^{14, 15} The most common are errors related to prescription, followed by errors in the administration of drugs or intravenous solutions.^16–18 Most studies published to date were only descriptive, and just a few of them assessed the impact of adopting preventive practices to avoid medication errors. We conducted a study that was designed to identify both the prevalence and the characteristics of prescription and administration errors to hospitalized newborns and children, before and after the implementation of several preventive interventions.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 
Study Design and Population
This before–after study was performed in 2 phases (June 2002 and May 2004). The population observed included (1) hospitalized patients between 0 and 18 years of age, (2) nurses who prepared and administered the medications and intravenous solutions, and (3) physicians who prescribed the drugs and intravenous solutions. The analysis included all prescriptions and administrations of a weekday and a full weekend in both phases.

Setting
The study was conducted at the Department of Pediatrics of the Hospital Italiano de Buenos Aires, a tertiary care university hospital. The Department of Pediatrics has 110 beds and 6500 annual admissions and 3 main inpatient divisions: NICU, PICU, and general pediatrics ward (GPW).

Physician orders are mainly prescribed by residents and fellows. There are specific sheets for each inpatient area. Orders are handwritten, and all medication orders are rewritten every day and also whenever an additional order or change is needed. Drugs and intravenous fluid solutions are prepared and administered by nurses from each area and work shift. A few drugs are prepared at the hospital pharmacy (chemotherapy, parenteral nutrition, oral morphine solution, oral caffeine, and dialysis solutions).

Interventions
A single, multifaceted intervention was performed mainly on the basis of an educational program developed by the Patient Safety Committee of the Department of Pediatrics, addressed to all health care professionals who are devoted to child care. The program was centered on the promotion of a cultural change in the approach to medical errors and on the development of a safety-oriented attitude that focuses on patient safety as a priority of medical practice, as in other high-risk human disciplines.^19–21 The program focused on health professionals' education by means of different activities: grand rounds, interdisciplinary meetings at every area of the department, task groups of residents and fellows, information retrieval on bibliographic databases, exchange of information with hospitals from other countries, and creation of a system for the anonymous reporting of errors. The program also considered determining the prevalence of medication errors and the identifying the most common errors. Specific strategies to reduce medication errors were developed. These strategies included (1) a modification in the process of prescription of medications, improving environment conditions (eg, reducing interruptions, telephone calls, change in the time schedule), and direct staff supervision, (2) active interaction with pharmacists during rounds, and (3) implementation of the "10 steps to reduce medication errors" checklist (see Appendix 1). These recommendations were stated during interdisciplinary meetings among physicians and nurses. Before the study was begun, a pilot test was performed to assess implementation of the aforementioned checklist. After this pilot test, many items were modified on the checklist, and a plastic pocket card was given to all clinicians to allow them to read the 10 steps to prevent errors in the prescription of medications and, on the other side, the 10 steps to prevent errors in the administration of medications. Every physician and every nurse had this card, and a copy of it was also placed where medications were prescribed, prepared, and administered.

Classification of Errors
On the basis of the American Society of Health-System Pharmacists standard definition of medication errors,²² we implemented different scales of errors in the prescription and administration of medications. Appendix 2 lists the prescription and administration-error classifications.

Description of the Study
During both phases of the study, every prescription and administration of medications and intravenous solutions was evaluated. All medications prescribed and administered to patients who were hospitalized at the Department of Pediatrics were included during a weekday and a whole weekend. The days were chosen at random, and the health care staff (physicians and nurses) were not aware that the study was being conducted. At every ward and ICU, error identification was done by a physician and a nurse who were specially trained (Dr Mariani and Ms Leyton). Both of them reviewed every chart together, and a third reviewer participated in case of disagreement (Dr Cernadas). The reviewers were not blinded, and there was not interrater reliability assessment. They collected the data only from patients' medical charts, medication prescription sheets, and nurses' records of medications and intravenous solution administration; no data were obtained through direct observation. The first cross-sectional phase analysis was done in June 2002, before preventive interventions were given; the second phase took place in May 2004, after implementation of the strategies previously described. During both phases of the study, methods did not change and were performed by the same researchers.

The main outcome variable was prevalence of medication errors during each phase. Secondary outcome variables were patients' age and gender; inpatient area (NICU, PICU, and GPW), time of the prescription order, and the administration (7:00 AM to 1:59 PM; 2:00 PM to 8:59 PM; 9:00 PM to 6:59 AM); number of written prescription orders and medication administrations during each phase of the study; type of identified errors; training level on the basis of postgraduate years of the physician who signed the prescription (junior residents [second year], senior residents [third and fourth years], or fellow or staff); education level of the nurse who prepared and administered the medication (registered nurse or licensed practical nurse), and adverse effects as a result of medication errors.

Statistical Analysis
Data were summarized according to a method of descriptive analysis. Error rates were estimated every 100 prescriptions and administrations. All information was recorded by using 2 x 2 tables to estimate the odds ratio (OR) with the error level set at .05 and a 95% confidence interval (CI) to consider the statistical analysis valid.

Logistic regression was used to evaluate variables that potentially were associated with medication errors in each patient included in both phases of the study. The variables that showed an important association with medication errors in the univariate analysis were included in the multivariate analysis by using multiple logistic regression.

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 
In the first cross-sectional phase analysis, in 2002, a total of 1764 medications (590 prescriptions and 1174 medication administrations) for 95 patients were evaluated. In the second cross-sectional phase analysis, in 2004, a total of 2732 medications (1144 prescriptions and 1588 administrations) for 92 patients were analyzed. Table 1 shows data regarding patients' characteristics and the hospitalization unit.

View this table: [in this window] [in a new window]   TABLE 1 Patient Data and Clinical Areas in Which Errors Were Evaluated

 
Prevalence of total errors was significantly lower in 2004 compared with 2002: 11.4% (201 of 1764) vs 7.3% (199 of 2732). The difference was –4.1% (95% CI: –2.3 to –5.8 [P < .05]; OR: 0.61 [95% CI: 0.50 to 0.75]; Table 2). The higher differences were observed in the NICU (7.8% [95% CI: 4.7% to 10.9%]; OR: 0.36 [95% CI: 0.25 to 0.52]). Likewise, the prescription error prevalence was significantly lower in the second phase, and an important reduction in administration errors was also observed (Fig 1, Table 2).

View this table: [in this window] [in a new window]   TABLE 2 Difference of Medication Error Rate Between the 2 Phases (2002–2004)

 

View larger version (10K): [in this window] [in a new window]   FIGURE 1 A, Prevalence of medication errors in both phases of the study (2002–2004). B, Prevalence of prescription and administration errors in both phases of the study (2002–2004).

 
In the second cross-sectional analysis, a reduction of errors was observed in most of the variables related to the category of physicians and nurses, time shift, and area. Differences are displayed in Table 3. There were no differences between weekday and weekend in neither of the 2 phases.

View this table: [in this window] [in a new window]   TABLE 3 Medication Errors in Both Phases of the Study According to Health Care Professional Category, Shift, and Working Area

 
The most frequent errors were the omission of the prescription order time and not administering a medication (Table 4). There was a significant reduction of potentially harmful administration errors in the second phase of the study: wrong dosing 30 (30%) of 99 in 2002 vs 9 (10%) of 95 in 2004 (P = .0003) and wrong infusion rate 13 (13%) of 99 in 2002 vs 0 of (0%) 95 in 2004 (P = .0002; Table 4).

View this table: [in this window] [in a new window]   TABLE 4 Types of Medication Errors (Prescription and Administration) Organized According to Phases Before and After Interventions

 
The regression analysis for the whole population in both phases showed that the most important risk factor for prescription error was patient age <2 months, whereas in administration error was patient age <1 year. Other significant variables are displayed in Table 5. No adverse effects were identified in either of the 2 phases.

View this table: [in this window] [in a new window]   TABLE 5 Variables Significantly Associated With Medication Errors in the Logistic Regression Analysis

 

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 
Hospitalized children are more susceptible to experiencing complications as a result of medication errors than adults,⁸ but, again, the adverse event rates seem to be similar (based on the limited data available). The reason is that adult patients receive standard doses, whereas newborns and children are medicated according to their weight and clinical condition, a fact that requires several calculations by the physician who writes the prescription, which increases the likelihood of errors. Moreover, most medicines are intended for adults and are presented as dosage forms that are in unsuitable concentration for children. As a result, clinicians who assist neonates, often extremely small, premature infants, have to adapt these drugs for children who cannot take adult dosage forms. This process requires a number of steps that increase the likelihood of mistakes. In other words, the omission of 1 step or a wrong calculation by using decimals can sometimes result in a dose 10 times higher than necessary (10-fold error).²³ This error can produce severe injury or even death, especially when medication agents have a narrow therapeutic window.

The study was developed in 2 phases. The first phase evaluated the prevalence of medication errors in every hospitalized child to assess the real scope of the problem before the intervention. Just as we have thought, the error rate during this first phase was very high, especially the prescription errors, with 1 mistake every 5 or 6 orders, almost doubling the administration error rate.

Certain studies reported similar rates or even higher. Marino et al²⁴ observed 24% of medication errors, being 84% of the former prescription errors. Other reports, written by pharmacists with a different method, described lower rates.^{8, 25} Nevertheless, Kaushal et al,¹⁶ in a more recent study, described a medication error rate of 5.7% in 2 academic pediatric institutions.

As in other studies performed, the errors were more frequent in the NICU,¹⁶ followed by the GPW. It is important to note that in the GPW, 40% of the patients were admitted to the oncology area, where a higher error rate has been reported.²⁶

During the second phase of the study, an important reduction of medication errors was observed. The intervention was specifically focused in promoting a cultural change among professionals about error approach. Hiding the error has been the predominant culture in medicine, believing that only incompetent or irresponsible health professionals make mistakes and promoting punitive measures toward them. Traditional models of medical education reinforce the concept of infallibility, assuming that if nurses and doctors have enough knowledge and skills, then they will not make mistakes. Through our program, which included all professionals involved in the care of newborns and children, an important change in the attitude toward the error was achieved. It was the first time that medical error was introduced as a subject in daily child care practices and rounds. Previous research has shown disparate results: whereas Bates et al²⁷ did not find positive results of a team intervention on the rate of medication errors, Cohen et al,²⁸ conversely, showed that changes in the attitudes of health care personnel toward patient safety can be achieved through a comprehensive program. We believe that this cultural change was the most important achievement of the program. The intervention had a greater effect in the prevention of prescription errors: on the basis of our findings, the number needed to treat was 25 (95% CI: 17 to 43).

No adverse effects related to medication errors were found, perhaps because a cross-sectional study is not the best design to identify a causal association between the error and the adverse event. Other limitations are that the study was conducted at 1 institution in 1 region and that the reviewers who identified the errors were not blinded.

Note also that the time between both phases was longer (2 years) than usual in a cross-sectional study. Nevertheless, the need to set a cultural change regarding error in medicine, as the main objective of the intervention, obliged us to extend the time between phases because it is a slow, complex, and difficult task in the short-term.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 
According to our results, intervention through a comprehensive program for prevention of errors, including all personnel involved in the medication process, achieved an important reduction in the prevalence of medication errors. Similar programs could increase safety in hospitalized children, a more vulnerable group to complications as a result of medications.

	APPENDIX 1: 10-STEP CHECKLIST

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 
10. Steps for Reducing Prescription Errors of Medications and Intravenous Solutions

1. Do not write a prescription order during inadequate environmental conditions and during time frames that are more susceptible to distractions.
   
2. Always verify that
   1. the prescription order corresponds to the patient; and
      
   2. the patient's name appears in the indication sheet.
      
   
   
3. When writing a prescription order,
   1. use legible handwriting (eg, you can use capital letters);
      
   2. indicate the name of the generic drug;
      
   3. state dose, dosage interval, dilution, route of administration, and infusion time;
      
   4. use a comma instead of a point when writing decimals;
      
   5. do not use abbreviations, corrections, or emendations; and
      
   6. indicate the prescription order time.
      
   
   
4. Explain whether there is any incompatibility with other medication or with the diluting liquid.
   
5. Agree with the nursing staff the best time to administer a medication, to check the patient after medication administration.
   
6. Do not repeat the indications of the former day writing phrases such as "same indications." Prescription orders must be revised and written again.
   
7. Use capital letters when writing modified next to a previous indication written the same day, and tell the nurse personally.
   
8. Repeat the calculations 2 or 3 times when a medication requires various dilutions, and write the dilution clearly (avoid the 10-fold dose error).
   
9. To conclude,
   1. revise everything that has been written;
      
   2. verify the calculation of the dose;
      
   3. verify whether something important has been omitted or whether there is any confusing indication; and
      
   4. sign the prescription order and write your surname clearly.
      
   
   
10. Every prescription, without exception, must be revised by another physician before indicating it, and this physician must write "checked by... ."
    

A prescription order is not a routine act. Every time you write a prescription order, review this 10-step checklist.

10. Steps for Reducing Administration Errors of Medications and Intravenous Solutions

1. Do not administer medications or solutions when
   1. there is a doubt regarding the prescription order;
      
   2. the handwriting is not legible or there are emendations; or
      
   3. the time and date of the prescription order are not written.
      
   
   
2. Before administering a medication,
   1. check the patient;
      
   2. verify that the medication corresponds to this particular patient (pay special attention in the case of patients whose surnames are similar); and
      
   3. verify the dose, route of administration, and infusion time.
      
   
   
3. Do not mix different drugs in syringes, tubing connections, or infusion solutions if you are not sure about the compatibility of the drugs.
   
4. Do not administer a medication when the prescription order says "same indications."
   
5. Always supervise medications that are given by family members. The nurse must record and sign the medication sheet.
   
6. Check the patient before the administration of the medication and afterward. Record this control in the medication sheet.
   
7. Be careful when diluting medications. Always remember that
   1. inattentiveness is dangerous; and
      
   2. when more that 1 dilution is necessary, it is imperative that more than 1 person participate in the process (nurse/nurse or nurse/physician).
      
   
   
8. Do not administer a medication when the indication was given orally. If it was an urgent case, then always ask the physician to write down the prescription order afterward.
   
9. In the end, use legible handwriting to record
   1. problems during the administration of the medication;
      
   2. unexpected effect of the medication on the patient; and
      
   3. signature, time, and name of the nurse.
      
   
   
10. When you have doubt regarding a particular medication, always ask the physicians.
    

Always read this 10-step checklist before administering a medication. It will contribute to reducing medication errors.

	APPENDIX 2

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 
Classification of Prescription Errors

1. No error
   
2. Wrong medication (eg, is contraindicated for the patient or belongs to another)
   
3. Wrong dosing: total daily dose or charge and maintenance; includes errors such as using milligrams (mg) instead of micrograms (µg)
   
4. Omission of a drug that was being administered and it is not stated that it was suspended
   
5. Omission of a written prescription of an administered medication (verbal orders)
   
6. Omission of time an administered drug was prescribed
   
7. Inadequate route of administration
   
8. Error in dosing interval
   
9. Inadequate dilution of a drug or solution
   
10. Inadequate indication or omission of the infusion time of a drug
    
11. Inadequate intravenous infusion rate
    
12. Illegible order (based on ref ²¹)
    

Classification of Administration Errors

1. No errors
   
2. Wrong frequency (30 minutes before or 1 hour after the prescribed time)
   
3. Wrong administration (wrong drug or wrong patient)
   
4. Wrong delivery route
   
5. Omission: no administration of a drug
   
6. Wrong dosing: total or single dose
   
7. Error in dilution
   
8. Wrong infusion rate
   

	ACKNOWLEDGMENTS

 
We thank Gabriela Rodríguez Loria, MD, for invaluable help in statistical analysis and Pablo Durán, MD, for reviewing the manuscript.

	FOOTNOTES

 
Accepted May 28, 2008.

Address correspondence to Paula Otero, MD, Hospital Italiano de Buenos Aires, School of Medicine, Department of Pediatrics, Gascon 450 (1181), Ciudad Autonoma de Buenos Aires, Argentina. E-mail: paula.otero{at}hospitalitaliano.org.ar

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS APPENDIX 1: 10-STEP CHECKLIST APPENDIX 2 REFERENCES

 

1. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324 (6):370 –376[Abstract]
2. Leape LL. Error in medicine. JAMA. 1994;272 (23):1851 –1857[Abstract/Free Full Text]
3. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324 (6):377 –384[Abstract]
4. Ceriani Cernadas JM. Errors in medicine: reflections about its causes and the need of a more critical attitude in our profession. Arch Argent Pediatr. 2001;99 (6):522 –529
5. McIntyre N, Popper K. The critical attitude in medicine: the need for a new ethics. Br Med J (Clin Res Ed). 1983;287 (6409):1919 –1923[Medline]
6. Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The "To Err Is Human" report and the patient safety literature. Qual Saf Health Care. 2006;15 (3):174 –178[Abstract/Free Full Text]
7. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277 (4):307 –311[Abstract/Free Full Text]
8. Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. JAMA. 1990;263 (17):2329 –2334[Abstract/Free Full Text]
9. Muñoz Labián M, Pallás Alonso C, de La Cruz Bertolo J, López Maestro M, Moral Pumarega M, Belaustegui Cueto A. Medication errors in a neonatal unit [in Spanish]. An Esp Pediatr. 2001;55 (6):535 –540[Medline]
10. Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2 (8659):374 –376[CrossRef][Web of Science][Medline]
11. Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83 (6):492 –497[Abstract/Free Full Text]
12. Vincer MJ, Murray JM, Yuill A, Allen AC, Evans JR, Stinson DA. Drug errors and incidents in a neonatal intensive care unit: a quality assurance activity. Am J Dis Child. 1989;143 (6):737 –740[Abstract/Free Full Text]
13. Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111 (4 pt 1):722 –729[Abstract/Free Full Text]
14. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277 (4):301 –306[Abstract/Free Full Text]
15. Johnson JA, Bootman JL. Drug-related morbidity and mortality: a cost-of-illness model. Arch Intern Med. 1995;155 (18):1949 –1956[Abstract/Free Full Text]
16. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285 (16):2114 –2120[Abstract/Free Full Text]
17. O'Shea E. Factors contributing to medication errors: a literature review. J Clin Nurs. 1999;8 (5):496 –504[CrossRef][Web of Science][Medline]
18. Wong IC, Ghaleb MA, Franklin BD, Barber N. Incidence and nature of dosing errors in paediatric medications: a systematic review. Drug Saf. 2004;27 (9):661 –670[CrossRef][Web of Science][Medline]
19. Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142 (9):756 –764[Abstract/Free Full Text]
20. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293 :2384 –2390[Abstract/Free Full Text]
21. Leape LL, Woods DD, Hatlie MJ, Kizer KW, Schroeder SA, Lundberg GD. Promoting patient safety by preventing medical error. JAMA. 1998;280 (16):1444 –1447[Free Full Text]
22. ASHP Standard definition of a medication error. Am J Hosp Pharm. 1982;39 (2):321[Medline]
23. Kozer E, Scolnik D, Keays T, Shi K, Luk T, Koren G. Large errors in the dosing of medications for children. N Engl J Med. 2002;346 (15):1175 –1176[Free Full Text]
24. 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 –135[Medline]
25. Folli HL, Poole RL, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics. 1987;79 (5):718 –722[Abstract/Free Full Text]
26. Trinkle R, Wu JK. Errors involving pediatric patients receiving chemotherapy: a literature review. Med Pediatr Oncol. 1996;26 (5):344 –351[CrossRef][Web of Science][Medline]
27. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280 (15):1311 –1316[Abstract/Free Full Text]
28. Cohen MM, Kimmel NL, Benage MK, Hoang C, Burroughs TE, Roth CA. Implementing a hospitalwide patient safety program for cultural change. Jt Comm J Qual Saf. 2004;30 (8):424 –431[Medline]

---

PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				G. M. Kenney, J. Ruhter, and T. M. Selden Containing Costs And Improving Care For Children In Medicaid And CHIP Health Aff., November 1, 2009; 28(6): w1025 - w1036. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Otero, P. Search for Related Content PubMed PubMed Citation Articles by Otero, P. Related Collections Office Practice Social Bookmarking                         What's this?