Pediatric medication errors: what do we know? What gaps remain?

Patient safety is an increasingly well-recognized public health problem. The Institute of Medicine’s report entitled To Err Is Human1 initially drew widespread attention to this issue by estimating that approximately 44 000–98 000 deaths each year result from medical mistakes in hospitals. These estimates came from 2 main studies: the Harvard Medical Practice Study and the Colorado-Utah Study.2–4 Even though controversy surrounds the extrapolation of these numbers to national estimates, most agree that patient safety can be significantly improved.2,3 The Harvard Medical Practice Study found that medication errors are the most frequent type of medical errors, comprising over 19% followed by wound infections (14%) and technical complications (13%).2,3 This finding prompted further study of medication errors in adult inpatients, documenting a medication error rate of 5/100 medication orders, with 7 in 100 errors having a potential for injury (potential adverse drug event [ADE]) and 1 in 100 errors resulting in an ADE.5 A later Adverse Drug Event Prevention Study documented 6.5 ADEs per 100 adult admissions.6 Other studies demonstrated that ADEs are costly and can have severe sequelae,7,8 as well as high frequencies of medication errors in adult outpatients.9,10 In comparison, relatively few studies of medication errors have focused on children. In this article, we discuss why children are particularly prone to errors and review pediatric studies of medication errors. We then explore potential prevention strategies using a systems-based approach as advocated by the Institute of Medicine report, Crossing the Quality Chasm.11 This report identified 6 specific aims for quality improvement in health care, with safety leading the list, and emphasized that ensuring safety requires a systems-based approach to the development and