PublicationsSystematic reviewsPaediatric medication error
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Paediatric medication error: a systematic review of the extent and nature of the problem in the UK and international interventions to address it

What do we want to know?

Paediatric medication errors (PME) are failures in the treatment process that cause, or have the potential to cause unnecessary pain or harm to child patients and, in extreme cases, can result in death (Aronson 2009*; Department of Health 2006**). Medications may be given incorrectly (or omitted) either unintentionally or in ignorance, i.e. a mistake or slip in the medication treatment process. This review examines evidence on three key issues: the extent and nature of the problem in the UK; whether interventions, such as electronic prescribing (EP) or decision support tools, can reduce PME incidents; and what the key features of successful interventions are, to establish how effective interventions can be developed and implemented successfully.

Who wants to know?

The review was commissioned by the Department of Health (DH) in England to support the work of the Children and Young People’s Health Outcomes Forum in tackling the problem of PME. It will inform policy-makers, commissioners, practitioners, advocates and researchers who have a remit to explore policy issues relating to the safety of medicines.

What did we find?

  • Dose errors appear to be a common problem in both primary care (strong evidence) and acute care (promising evidence). However, an accurate and comprehensive picture of the rates and types of PME in the UK is not currently available, largely because error reporting is often voluntary and there is significant inconsistency in the recording and categorising of errors.
  • International evidence on interventions to tackle PME shows strong evidence of effectiveness for electronic prescribing; evidence regarding the efficacy of CDSTs and education interventions is promising.
  • Evidence suggests that the way electronic prescribing systems are developed and implemented is crucial to their success; successful electronic prescribing systems require careful and considered development and implementation, should feature comprehensive decision support and should be customised for use with children.

What are the implications?

  • The review lends support to calls for improvements in error reporting and monitoring systems highlighted in recent NHS reviews.
  • Strong findings regarding the benefits of EP for use with children, and the clear guidance regarding critical features and development and implementation processes, mean that policy makers should address the lack of EP systems currently being used in paediatric and neonatal units in hospitals in England.

How did we get these results?

The systematic review method was used to assemble a comprehensive and unbiased summary of available research evidence on PME. The work involved employing rigorous methods for identifying and analysing available research evidence to answer the following research questions:

  • What is the nature and extent of paediatric medication error (PME) in the UK?
  • Which international interventions are effective for reducing the incidence of PME?
  • What are the key features of effective interventions and how can they be successfully developed and implemented?

The EPPI Centre reference number for this report is 2210. This report should be cited as:

Sutcliffe K, Stokes G, O’Mara-Eves A, Caird J, Hinds K, Bangpan M, Kavanagh J, Dickson K, Stansfield C, Hargreaves K, Thomas J (2014) 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. ISBN: 978-1-907345-73-9  


* Aronson JK (2009) Medication errors: what they are, how they happen, and how to avoid them. QJM: An International Journal of Medicine 102: 513-521.
** Department of Health (2006) Standards for better health. London: The Stationery Office.

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