Pediatric patients who are treated in general acute care hospitals are at increased risk of medication errors. The main reasons are the lack of experience with the special needs of pediatric patients, their lower ability to tolerate medication errors, medication-related problems such as forms and packaging designed primarily for adults and labeling with insufficient information on the dosing of pediatric patients. Medication errors can be reduced significantly by appropriate medication management systems. Computerized Provider Order Entry (CPOE) systems reduce the frequency of medication errors in all stages of the process. IT technology introduces an additional vulnerability in the form of IT-related medication errors. Nurses are the last individuals in the medication management process who can detect and intercept a medication error and prevent incorrect medication orders from reaching and harming their patients. To be able to do so, nurses have to be familiar with the medication management system in their hospital and escalate incorrect orders as appropriate and relevant.

1. Addressing pediatric medication errors in ED setting utilizing Computerized Provider
Order Entry (CPOE) systems
Published April, 2017
Part of scenarios for detection of medication errors
Pediatric patients who are treated in general acute care hospitals are at increased risk of
medication errors. The main reasons are the lack of experience with the special needs of pediatric
patients, their lower ability to tolerate medication errors, medication-related problems such as
forms and packaging designed primarily for adults and labeling with insufficient information on
the dosing of pediatric patients. Medication errors can be reduced significantly by appropriate
medication management systems. Computerized Provider Order Entry (CPOE) systems reduce
the frequency of medication errors in all stages of the process. IT technology introduces an
additional vulnerability in the form of IT-related medication errors. Nurses are the last
individuals in the medication management process who can detect and intercept a medication
error and prevent incorrect medication orders from reaching and harming their patients. To be
able to do so, nurses have to be familiar with the medication management system in their
hospital and escalate incorrect orders as appropriate and relevant.
The pediatric patient population treated in an emergency setting in general acute care hospitals is
at increased risk of medication errors. The underlying reasons fall into three broad categories:
Lack of experience with pediatric patient population, causes relating to medication form,
packaging and labeling, and special needs of pediatric patients.
The U.S. Department of Health and Human Services (2014) in their report “National Action Plan
for Adverse Drug Event Prevention” recognized pediatric population as especially vulnerable to
adverse drug effects, along with elderly patients and people with low socio-economic status or
those with difficult access to healthcare (p. 7). Adverse Drug Events account for a large share of
hospital-related complications and post-discharge complications. They are the reason for
approximately 1 million emergency department visits annually, of which about 125,000 are
hospital admissions. (p.5). Grissinger (2015) stated that pediatric inpatients may experience
three-times more medication errors than adults and that 1% of all 100 errors have a significant
potential for harm (p. 96).
According to the Agency for Healthcare Research and Quality (AHQR, 2015), an adverse drug
event (ADE) stands for “harm experienced by a patient as a result of exposure to a medication.”
Not all ADEs are caused by a medication error, and not all medication errors result in harm to a
patient. A medication error stands for any error in the process, from prescription to administering
the drug to a patient, regardless of the harm caused. Medication errors that did not reach the
patient but could easily have are called potential ADEs. Whilst preventable ADEs are caused by
a medication error, non-preventable ADEs, or side effects (adverse drug effects) are linked to the
nature of the medication itself (AHQR, 2015).
In addition, pediatric patients are at increased risk of adverse drug effects due to pharmacokinetic
differences at various developmental stages, complex calculations required to adjust individual
doses, and the need for precise medication delivery systems. Packaging and formulation of most

2. medications are designed primarily for adults, and reliable information on pediatric use is often
unavailable. Moreover, young, small, or sick children have a lower capacity to tolerate
medication errors because their organ systems are still maturing. The inability of small children
to communicate any undesired effect of medications compounds the problem (Grissinger, 2015).
Medication management is a complex process that starts with a physician prescribing the drug
and continues through transcription by assistants to a pharmacist who prepares and dispenses the
drug, labeling for individual patients, and administration to patients as appropriate. Once dosed,
nurses and clinicians monitor patients for therapeutic and unintended effects of medications.
Patients who receive high-risk medications may also be monitored for pharmacokinetic effects of
the medication (Carayon et al., 2014).
Each hospital has a unique medication management system. Some hospitals have their
medication management systems entirely paper-based; others use entirely computerized
solutions, including electronic health records and interfaces with automated dispensing cabinets,
storage and logistics systems, prescription order systems, pharmacy information systems, faxes,
and printers, infusion pumps, and laboratory diagnostic equipment. In most instances, however,
the systems consist of the combination of a wide range of electronic solutions in various stages
of implementation and paper-based legacy systems that also serve as a back-up should the
computers fail.
Computerized Provider Order Entry (CPOE) systems are increasingly popular due to their ability
to reduce medication errors. Radley et al. (2012) studied how many medication errors were
averted by the processing of medication orders through CPOE since the implementation of
HITECH Act in 2008, and argued that CPOE systems significantly reduced the likelihood of
medication errors in inpatient acute-care settings by 48% (p. 480).
Carayon et al. (2014), in their paper “Characterizing the complexity of medication safety using a
human factors approach: An observational study in two intensive care units,” examined
medication safety in two intensive care units. Medication errors tended to cluster in groups,
meaning that a single step in the process includes more than one error. Sequential errors span
multiple stages of the process. A detailed overview of the medication management process
identified all steps and potential vulnerabilities where errors could occur. Specifically, the team
was looking for incomplete orders, order modifications and pharmacy clarifications, duplicates,
illegibility, unapproved abbreviations, instances when a patient received a medication despite
documented allergy, delayed or omitted administration, the use of antidotes, patient symptoms
and out-of-range laboratory values, and references to medication errors in medical notes (p.5).
Most errors occurred at the ordering (prescription) and administration stages. Most frequent
types of errors were late and omitted administration; medications dispensed late or not at all,
wrong order information, omitted information, and wrong dose. The reason for late or omitted
administration of medication was often due to the unavailability of the drug in the medication
room (p. 8). Information about temporal sequences and grouping of errors is important for
system redesign (Carayon et al., 2014).
Grissinger (2015), in his analysis of pediatric medication errors, mentions additional sources of
human error, namely IV line mix-ups, mix-ups of look-alike and sound-alike medication

3. packaging and names, and bioavailability problems linked to modification of adult drug forms
for pediatric use (p. 99).
While the implementation of CPOE systems in hospitals is effective in preventing a significant
number of medication errors, the system itself can become a major source of an additional type
of errors. Cheung et al. (2013) analyzed over 4.000 IT-related medication incidents caused either
by the technology itself or by human-machine interaction. A significant number of erroneous
exchanges concerned choosing the wrong medicine due to poor design of computer screens, and
data exchange failures when communicating with other interfaces such as bar code scanning
systems, automated dispensing cabinets, health information systems, printers and infusion pumps
(p. e63). To analyze IT-related medication errors, Cheung et al. adapted the 2012 version of the
Magrabi classification. Magrabi classification defines 32 preferred terms to describe the source
of the IT problem and the nature of the error. Nature of the IT-related medication errors included
“no input”, “wrong input”, “failure to communicate after input”, “data retrieval”, “no output”,
“wrong output”, “unclear output”, “failure to react on signal”, “other output”, “data transfer”,
“mistranslation of data between two systems” and “no data transfer between two systems” (p.
e66). IT-related errors can affect all stages of the medication management process, from
prescribing, transcription, data entry into the pharmacy information systems, compounding,
dispensing, administration, patient monitoring and storage, and logistics (p. e68). The practical
implications of IT-related medication errors include an awareness that errors of this kind can
occur, and the need for a back-up solution recognized at an organizational level (Cheung et al.,
2013).
Drug shortages further complicate medication management due to the need for correcting and
reprocessing existing orders and replacing standardly used medications with other, less familiar,
and less suitable options. Improvisation forced by the unavailability of certain medications leads
to additional delays and adverse outcomes in patients. A recent study sponsored by the Office for
Clinical Practice Innovation, The George Washington School of Medicine and Health Sciences
(2015), explored trends in U.S. drug shortages for medications used in emergency departments in
the past 13 years. Of the 1.798 studied shortages, 610 (33.9%) fell into the scope of emergency
medicine. Drugs most frequently on shortage included acyclovir injection, hydromorphone,
polyvalent antivenin injection, epinephrine, pantoprazole, dexamethasone, calcium chloride,
diphenhydramine, tetracaine eye drops and many others (Hawley, Mazer-Amirshahi, Zocchi, Fox
& Pines, 2015).
Nurses find themselves at the end of the hospital’s medication management systems. As such,
nurses are the last line of defense and the last individuals who have the ability to detect a
medication error and intercept the erroneous flow of information before the medication reaches
the patient. Nurses are also the people who have to follow-up any missing information,
incomplete orders, miscommunication, and errors to be able to administer the correct dose of the
right medication to the right patient at the right time. In the case of IT-related failures, nurses
have to be able to retrieve the correct information from hospital back-up systems, and bridge
information flow between systems that are either not designed to communicate or that
occasionally fail to do so.
To be able to detect and intercept a medication error, nurses have to be intimately familiar with
their hospital’s medication management system and understand the vulnerabilities to human or

4. machine error such systems have. Awareness of common sources of errors improves the ability
of nurses to detect medication errors, respond appropriately, and prevent erroneous orders from
reaching and harming their patients. Easy-to-use and punishment-free error reporting systems are
essential for the system to self-correct and continuously improve.
Pediatric patients are at increased risk of medication errors when treated in non-specialized
emergency care hospitals. Errors can occur in all stages of the process, from prescription and
transcription to compounding, dispensing, administration, and monitoring. Computerized
provider order entry systems are an essential tool implemented in many hospitals to manage
information related to medication flow intended to decrease the incidence of medication errors.
Although effective, these systems can become an additional source of errors due to the nature of
machines and human-machine interaction. Drug shortages are a common complication in the
medication management chain. Nurses are the last line of defense in the medication management
system, and the last individuals capable of detecting and intercepting medication errors before an
incorrect medication reaches the patient. Familiarity with the whole medication flow is necessary
for the individual ability to mitigate such errors.
References
Agency for Healthcare Research and Quality. (2015, March). Medication Errors. Retrieved
March 25, 2017, from https://psnet.ahrq.gov/primers/primer/23/medication-errors
Carayon, P., Wetterneck, T. B., Cartmill, R., Blosky, M., Brown, R., Kim, R. Walker, J. (2013).
Characterizing the Complexity of Medication Safety using a Human Factors Approach: An
Observational Study in Two Intensive Care Units. British Medical Journal, 23(1), 56-65.
doi:10.1136/bmjqs-2013-001828
Cheung, K., Veen, W. V., Bouvy, M. L., Wensing, M., Patricia M L A Van Den Bemt, & Peter
A G M De Smet. (2014). Classification of medication incidents associated with information
technology. Journal of the American Medical Informatics Association, 21(E1).
doi:10.1136/amiajnl-2013-001818
Grissinger, M. (2015). Medication Errors Affecting Pediatric Patients: Unique Challenges For
This Special Population. Pennsylvania Patient Safety Advisory, 12(3), 96-102. Retrieved March
25, 2017,
from http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Sep;12(3)/Pages/96.
aspx
Hawley, K. L., Mazer-Amirshahi, M., Zocchi, M. S., Fox, E. R., & Pines, J. M. (2015).
Longitudinal Trends in U.S. Drug Shortages for Medications Used in Emergency Departments
(2001-2014). Academic Emergency Medicine, 23(1), 63-69. doi:10.1111/acem.12838
Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse
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5. Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw,
B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider
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