CHAPTER 2

LITERATURE REVIEW

A literature review is a crucial part of research that contributes to our understanding of the

study's topics. It is specifically designed to give a thorough comprehension of the prior research

that is pertinent to the subject or field of study. The current research focuses on Medication

errors in children, which requires a comprehensive understanding of the epidemiology of

Medication errors, types of medication errors associated with pediatric patients, Common

medications associated with these errors, causes and risk factors as well as prevention and

mitigation strategies to reduce these errors. This chapter provides detailed information on all the

pertinent data pertaining to the points mentioned above.

2.0 GLOBAL EPIDEMIOLOGY OF MEDICATION ERRORS

Harm from MEs accounts for over half of the overall preventable harm in medical care globally,

with an estimated annual cost of €4.5–21.8 billion in Europe (Hodkinson et al., 2020).

Medication errors are among the leading cause of injury and avoidable harm in healthcare system

worldwide. Globally the estimated cost with medication errors is $42 billion annually

(WHO,2022). Patient injury during Healthcare treatment are the one of the major causes of

morbidity and mortality making medication safety an international priority. WHO defines patient

harm as “an incident that results in harm to a patient such as impairment of structure or function

of the body and/or any deleterious effect arising there from or associated with plans or actions
taken during the provision of health care, rather than an underlying disease or injury, and may

be physical, social or psychological (e.g., disease, injury, suffering, disability and

death)”(WHO, 2010).

The severity of medication related errors at any stage of the healthcare delivery can range from

minor to serious, which can lead to harm and death, with associated health care and other

financial cost (Ferner et al.,2010). The US Institute of Medicine “To err is human: Building a

safer health system” (Kohn et al.,2001) provided information that has helped to generate a

movement for patient safety in which it reported that, each year in the United states, up to 98,000

deaths are due to medical errors, and at least some could have been avoided (Stelfox et al.,2006).

In March 2017, WHO launched a global campaign the Global Patient Safety Challenge:

Medication Without Harm to reduce severe, preventable medication errors in all countries by

50% for over 5 years. (WHO,2017).

This campaign aimed to correct the faults in the healthcare system that created areas for

medication errors and harm in patients with a focus on 4 domains patients and the public,

healthcare professionals, medicines and systems and practices of medication. A study showed

that 237 million medication errors happen at some point in the medication delivery process in

England annually, 66 million of which a very clinically relevant (Elliot et al.,2021). A systematic

review and meta-analysis of 81 observational studies consisting of 285,687 patient records by

Hodkins et al showed that 3% of patient experienced avoidable medication errors and about one-

fourth of those errors were potentially harmful and life-threatening (Hodkins et al.,2020). The

findings were also synonymous with another review which showed that the prevalence of

medication errors in patients was 6%, one-tenth of which were life-threatening (Panagioti et

al.,2019). Medication errors are the 3rd most common cause of mortality in the United States,
after heart disease and cancer (Makary et al.,2016). An estimated of over 7000 people in the

USA pass away due to medication errors each year, and approximately 1.3 million people

experience harm due to these mistakes. (Wittich et al.,2014). An implication of these mistakes

and Adverse drug events due to these errors include psychological and physical discomfort and

loss of trust in the healthcare system (Wittich et al.,2014).

Medication errors pose major financial burdens on the healthcare system globally. The cost

associated with Medication errors has been estimated at 42$ US dollars annually (WHO,2023).

These avoidable errors were estimated to cost the National Health Service in England £98

million per year, with 181 626 hospital days and leading to over 1000 deaths. Medication errors

that take place in primary health care for hospital admissions contribute to £83.7 million; 627

deaths and in the secondary care system leading to increased hospital stays costing £14.8 million;

causing or contributing to 1081 deaths (Elliot et al.,2019). While there are almost limited to no

studies addressing the cost of medication errors in pediatrics, it is estimated that medication

errors result in 21 billion dollars annually ( Silva, & Krishnamurthy, 2016).

2.2 TYPE OF MEDICATION ERRORS AMONG CHILDREN

Medication errors can occur anywhere along the medication cycle, from the clinician who

prescribes to the nurses who administer the medication. A Canadian study in pediatric patients

described that 8 % of emergency department visits were attributed to medication-related events,

of which two-thirds were deemed preventable. The different types of ME include but are not

necessarily limited to;

2.2.1 Dosing Error

especially in the intensive care unit (Jain et al.,2009). Children require personalized medication

based on their age and body weight, accompanied by the interpretation of the therapy outcome

(Lenor et al.,2008). Incorrect dose administered refers to a medication error in which a patient

receives a drug dosage that deviates from the prescribed or recommended amount, it may be

higher or lower than the actual prescribed dose (Truter et al.,2017). A wrong dose error can also

be described as a medication with the wrong dose strength, volume or concentration (Agyemang

et al.,2010). Factors contributing to dosing errors include miscalculations, miscommunication of

dose instructions, and lack of double-checking protocols. Studies show that dosing errors account

for a majority of administration errors in a pediatric setting, with rates as high as 28% in some

cases (Kaushal et al.,2001). In an audit of medication charts in an Australian pediatric

department, Dawson et al. found 52 major errors in 212 (24.5%) medication charts, with dosing

errors accounting for (12.3%) of them. In a prospective, multicenter study of medication errors

using comprehensive error detection methods in 2 academic pediatric hospitals, it was

discovered that errors occurred at a rate of 5.7 errors per 100 orders, with most of these errors

occurring at the ordering stage (79%), Many of these involved incorrect dosing (34%). A cohort

study on medication errors and intervention in pediatric medical settings containing the error

types, stages and services involved showed that the most frequent error out of the 626 MEs

recorded was incorrect dosage administration ( 28.4%).

Individualized dosing is one of the causes of pediatric MEs, where doses in the pediatric

population are usually calculated individually, based on the patient’s age, degree of prematurity

in neonates, weight or body surface area, and clinical condition these may lead to increased

opportunities for dosing errors ( Gonzales et al.,2010 ). According to a study conducted by Shah
RK [Shah et al.,2009), multiple errors occurred in every inpatient pediatric otolaryngology

admission. Shah reviewed 50 patient admissions; medication dosing errors occurred in 22% of

admissions and a total of 553 errors were discovered. These were predominantly mis-dosing of

acetaminophen and antibiotics (e.g., amoxicillin). To note, this study was conducted in a tertiary

pediatric medical center, so this was a different clinical environment than most pediatric

otolaryngology admissions worldwide, which occur in mixed adult-pediatric otolaryngology

departments. Toxicity may result from dosage mistakes in pediatrics, such as choosing the wrong

medication strength. Therefore, it is imperative to verify the medication, dosage, patient

identification, and any other pertinent information before providing medication (Wong et al.,

2009).

2.2.2 Transcription Errors

Transcription errors are defined as discrepancies in the medication (drug name, dose,

frequencies, and dosage form [tablets/pills/syrups/injections]) written in a patient’s progress

notes, medication chart, or drug order form, or in the nurse’s log book.

A transcription medication error occurs while transferring medication orders from one form of

documentation to another. This can happen, for example, when a healthcare provider writes a

prescription, and someone else, typically a nurse or pharmacy technician, transcribes that

prescription into the patient’s medication administration record (MAR) or electronic health

record (EHR). The error may occur for various reasons such as illegible handwriting,

misinterpretation of the prescriber’s instructions, or typographical mistakes during transcription.

These errors are significant as they often go unnoticed and can move through the medication

administration process, potentially causing harm to patients. A study carried out at a teaching

hospital showed that nearly 30% of medication transcription errors resulted in mistakes during
the drug administration process with omission being the most common type of error accounting

for over 50% of the errors (Ramzi et al.,2019). Handwritten prescriptions are more likely to lead

to such errors due to legibility and clarity issues, which can often be misinterpreted (Knudsen et

al.,2007). Illegible handwriting is still a significant contributor to transcription errors, especially

in settings where traditional handwritten orders are still utilized (Julia Clement,2015).

Abbreviations can also lead to misinterpretation, for example, the use of “IU” for international

units can be interpreted as “IV” for intravenous, potentially causing administration-related errors

(Ben Walker). This use of computerized medical records can mitigate this issue. Second in a

study conducted by Fortescue et al., to assess the effectiveness of intervention strategies used to

reduce medication errors found that, computerized physician order entry could have prevented a

large majority of errors. Basic CPOE, which ensures legibility and Completeness of orders but

would not include decision support, had the potential to prevent 65.9% of all errors in the study,

whereas CPOE with decision support could have prevented an additional 6.8% of all errors ( for

which transcription errors accounted for 15.9% of total errors) for a total error rate reduction

from CPOE of 72.7% (Fortescue et al., 2003).

2.2.3 Dispensing errors

Dispensing errors are defined as wrong dose, wrong patient, wrong drug, duplication, labeling

errors, wrong dosage form (whether pills or tablets [oral], or injections [E.g. intravenous]),

wrong quantity, drug omission, and drug dispensed although it was not charted on the drug /

Medication order form (Ernawati et al.,2014). The prevalence of dispensing errors in healthcare

settings varies widely across studies, with rates between 0.015% and 33.5% depending on the

healthcare setting and methods used (Aldwaihi et al.,2016). Dispensing errors often occur when
there are inconsistencies between the medication prescribed and what is dispensed. This can lead

to mistakes such as dispensing the wrong medication, incorrect dose, or wrong drug formulation.

According to Lisby et al., 2005 frequent dispensing errors included unordered drugs, unordered

dosages, incorrect doses and omitted doses. The study showed that 20% of identified dispensing

errors are potential causes for an adverse drug event in patients. Dispensing errors also occur

during the dispensing of drugs by hospital pharmacists, in an investigation of pharmacists, the

Massachusetts State Board of Registration in pharmacy estimated that 2.4 million prescriptions

were often filled inaccurately each year in Massachusetts (Knox, 1999). 86% of the errors

involved giving patients the wrong drug or incorrect drug strength (dose).

2.2.4 Omission errors.

The Pennsylvania Patient Safety Authority received reports of over 2,700 medication errors,

classified as drug omissions, involving over 500 different medications between January 1, 2013,

and April 30, 2013 (PSA, 2014) These Errors are of great concern, specifically in the pediatric

population, due to their unique vulnerabilities. Drug omission errors can lead to mild discomfort,

severe health complications, Adverse drug events, or even death, depending on the drug and the

patient's medical condition. Research done at the University Teaching Children Hospital in

Lusaka, Zambia, found that within the first 48 hours of patient admission, out of the 1,589 doses

ordered by physicians, only 1,132 were successfully administered, and 29.2% of the doses were

omitted. Showcasing the limitations of the healthcare delivery system (Kampamba et al.,2021).

Synonymously, the study also highlighted the prevalence of omission errors, accounting for

28.8% of administration errors in a hospital setting (Kampamba et al.,2021).

The causes of this omission range from various factors, stemming from unavailability of

medication, difficulty in pediatric dose preparation and calculation, to workflow and

(Stefano et al.,2021; Feyissa et al., 2020). Systemic problems such as insufficient

communication between the healthcare team, low mental stability due to increased working

demands, and over-dependence on the use of abbreviations can lead to an increase in Omission

errors. Omission errors may sometimes be overlooked compared to other errors as proven by a

study on pediatric nurses' perception of medication errors in which the nurses did not explicitly

consider missed doses a reportable error. In other words, nurses did not perceive the “error of

omission” (missed dose) to be as significant as the “error of commission” (wrong dose,

overdose). While the error of commission would be reported, they tended only to report missed

dose errors that had the potential for severe outcomes (Alomari et al.,2017).

2.2.5 Administration Errors

The most crucial stage of the medication process is the administration of the medication, this

stage is important as it is the point at which errors are very prone to occur. Not only do they

happen but mistakes made in this stage of the treatment process pose a danger to the pediatric

patient. Administration errors arise when there is a mistake in the delivery of healthcare services

(wrong rate of administration, wrong drug, wrong time, wrong route, wrong patient, etc)

(Agyemang et al.,2010). Because medication delivery mistakes are frequent and can pose a risk

to patients, they have been utilized as indicators of patient safety in hospitals (Oshikoya et

al.,2013).

The prevalence of drug administration errors in children is alarmingly high, and the need for

error-proofing interventions is paramount due to the high frequency of these errors in pediatric

settings (Marino et al.,2000). Kaushal et al., 2001 reported that medication administration errors
and the adverse effects that follow them are more evident and detrimental in children. Among

1788 patients in a prospective cohort trial conducted over two months at 6 office practices

(Kaushal et al.,2007), there were 57 (3%) avoidable adverse drug events (ADEs). 8 occurrences

(14%) were considered serious, although none were declared life-threatening. 40 (7%) have

anything to do with drug use by parents. Children who are on multiple medications are more

likely to be at risk of these mistakes (Zaindieh et al.,2008)

Several factors contribute to the increased occurrence of MAEs in pediatric healthcare. One

major cause is the difficulties attached to the drug dosage calculations. Hutton (2003) stated that

new prescribers often face challenges with appropriate medication calculation which can lead to

potential errors. Interruptions during the nursing task and administration rounds significantly

increase the risk of errors (Westbrook et al.,2010). In a study carried out in the intensive care

unit, it was discovered that the frequency of MAEs was significant with pediatric patients being

the ones majorly affected due to the need for individualized dosing and complex drug

measurement calculations ( Van den Bemt et al.,2002). Despite these findings reporting of

MAEs in pediatric settings is relatively low (Stratton et al.,2004). Nurses are the final link in the

medication delivery process and spend most of their shifts handling drug administration and

monitoring and are more likely to spot the occurrence of MAEs, Nurses are primarily responsible

for the administration of medications and therefore the rate of medication error is higher for

nurses compared to doctors, pharmacists, or other healthcare professionals (Keum Soon et al.,

2011). Several barriers prevent them from effectively reporting these errors, some of which

include fear of punishment and being reprimanded, and lack of confidence to report (particularly

in nursing students) (Koohestani et al.,2009) Previous studies have found that the reasons for

non-reporting of medication errors are that they are either not detected, hidden, easily fixed, or
because there is fear of the consequences of reporting (Prot et al., 2005). Wakefield et al.,1996

also discussed likely obstructions which may include concerns about professional reputation and

career and the potential for extreme disciplinary actions. Although there have been multiple

attempts to reduce medication errors in the pediatric setting (e.g., adding new technology such as

barcoding and providing additional education), sustainable and effective solutions for

administration errors are not obvious (Alomari et al., 2017). Medication administration creates a

lot of busyness during the ward’s peak medication times as various nurses participate in the drug

preparation process simultaneously working to prepare medications for their patients, reaching

over and around each other, as well as “talking over one another”. Additionally, some hospitals

might have strict double-checking policies that require extra nurses to double-check every drug

(as per the policy) resulting in overcrowding in the drug room as well as a sense of urgency to

get the work done. Various physical environmental issues also pose challenges to the

administration process some of which include lack of space in the medication room (where most

medications are prepared), lack of resources in the medication room (e.g., calculators, reference

books), essential supplies kept outside the medication room (e.g., computer) (Alomari et

al.,2017).

2.2.5 Prescription Error

Prescription errors fall into two basic categories: commission errors, which include adding

incorrect information, and omission errors, which involve omitting important information (Kozer

et al., 2002). Nevertheless, prescription errors for medications can be avoided; the pediatric

group was shown to have a high prevalence and clinical impact of these errors. Children are

more vulnerable to the negative effects of medication prescribing errors than adults because of a
variety of factors, including rapid physiological change, pharmacokinetic variations, organ

maturity, and age and weight variations (Ferner et al.,2009; Kozer et al.,2006; Otero et al.,2008).

In an analysis of 682 children admitted to a Congenital Heart Disease Center at a teaching

hospital in the United Kingdom, 441 medication errors were reported by nurses, doctors, and

pharmacists, of which prescribing errors accounted for 68%, followed by administration errors

(25%) and supply errors (Willison et al.,1998).In an analysis of 1000 patients drawn from a

community office-based medical practice, 23 patients experienced potentially avoidable

discomforts which 10 of were due to physician error (i.e., six due to administration of a drug not

indicated and four to improper drug administration) (Kohn et al.,2001; Burnum, 1976). Kohn et

al deduced that physicians may not routinely screen for potential drug interactions, even when

medication history information is readily available, hence errors occur more frequently during

the prescription of a medication.

Based on research conducted by Morh et al. 47 medication mistakes out of 147 medical errors

recorded from 14 pediatric clinics were connected to ordering, with 55% having to do with

ordering, 30% having to do with failing to order, 11% with administration, 2% with transcribing,

and 2% with dispensing. 10.1% of the 1532 children at another pediatric emergency room

reported prescription mistakes related to medications. medication errors in a pediatric emergency

room at a tertiary children's hospital were reported by Vilá-de-Muga et al. Of the 377 entries that

had a prescription for treatment, 92 errors (15%) were found though none of the prescription

errors were thought to be serious. Pharmacists must review orders and prescriptions to identify

mistakes and shield patients from unfavorable effects (FMHACA,2012; Ghaleb et al.,2006).
2.3 Type of Medication Commonly involved in these Errors

2.3.1 Antibiotics

According to a study conducted in 2021 by Christine et al. on medication errors and adverse

drug responses in pediatrics, Antibiotics for systemic use were the most commonly reported drug

class in pediatric medication mistakes (n=121, 15.7%). Antibiotics and other systemic use

antibacterial were among the most often reported drug classes associated with pediatric

medication errors (Christine et al.,2021). Antibiotics are regarded as essential medicines used in

the treatment of infectious diseases and are most frequently used in pediatric settings for

the treatment of common bacterial infections ( e.g. penicillin). One of the most common

diagnoses in a pediatric ward in most underdeveloped countries is mainly infectious diseases,

which necessitates the use of antimicrobial therapy (Feyissa et al.,2020). According to Yewale et

al. (2012), antimicrobial medicines can be empirically given without waiting for a definitive

identification of the causal agent. Cross-sectional research conducted at the Nekemte Referral

Hospital in Western Ethiopia found that, based on culture and sensitivity data, only 1.3% of

recommended antibiotics were administered. This was largely caused by financial limitations and

a lack of facilities in settings with low resources, such as the study hospital where it is

impractical to do sensitivity and culture tests on every patient. The microbiological tests carried

out in the setup were solely for study and inquiry, as well as in certain situations where resistance

was thought to exist (Fekadu et al., 2019).

2.3.2 Analgesics
Another prominent drug class commonly involved in pediatric medication errors is analgesics,

which include pain medications such as opioids, and nonsteroidal anti-inflammatory drugs

(NSAIDs). Analgesics which are used for pain treatment, are essential in pediatric care but offer

serious dangers when errors occur. In pediatric healthcare, analgesics are frequently used to treat

pain which results from a variety of illnesses and treatments (Amy et al.,2019). But due to their

wide use, they are also frequently the cause of drug errors. In a pediatric hospital setting,

analgesics were responsible for 17% of all drug mistakes, according to a study by Kaushal et al.,

(2001). In a study by Mcphillips et al consisting of 1933 randomly selected children receiving

new prescriptions using automated pharmacy data from 3 health maintenance organizations,

major errors were identified with Patients receiving ≥5 prescriptions had more dosing errors

than children with a single prescription. Most of which include analgesics (15% overdosed). The

most commonly reported drug classes associated with errors were antibiotics and sedatives. This

may be because these classes of drugs are the most widely prescribed. In addition, a majority of

the drugs commonly involved in MEs have a narrow therapeutic index and, hence, may lead to

serious consequences. The intravenous route is the most common route associated with MEs in

children. (ghaleb et al.,2006).

2.3.3 Vaccines.

High-risk practice areas, such as neonates and NICU settings where vaccines are one of the key

medications of emphasis, were highlighted by a study as appropriate places to start for quality

improvement activities, neonates (291; 19%) and infants (230; 15%) were most likely to be

involved in reported errors and vaccines accounting for (93; 6%) of the mistakes alongside

Analgesics and Intravenous fluids (Conn et al.,2020). In a community setting, vaccines

class most commonly engaged in these errors.

Reports of medication incidents are often linked to vaccinations. Vaccines can be inadvertently

given when they shouldn't be, when they have already been given, or when parental consent has

been declined. It is frequently the case that inadequate mechanisms exist for recording

immunization records (NPSA, 2009).

2.4 CAUSES AND CONTRIBUTING FACTORS

Medication errors in Pediatric settings can be caused by various factors in the healthcare system,

these causes can vary from human-based causes, Organizational causes, and Environmental

causes, the errors might also result as a result of a combination of the various factors in a hospital

setting. These factors are mostly associated with the perpetrators of these errors (Nurses), who

handle the administration of these medications as well as the monitoring of the administered

medication therapy in these patients.

2.4.1 Human Factors

[Link] Workload

Heavy workload in nursing refers to an overwhelming amount of work responsibilities and

demands on the part of nurses that must be completed within a short period. As a result, nurses

can be overloaded or fatigued easily by this severity of voluntary overtime. It undermines their

ability to deliver high-quality patient care (Pronovost et al., 2005). Causes for heavy workload in

nursing are inadequate staffing levels, highly complex patient needs; frequent interruptions, and

extra non-nursing tasks are some of the reasons nurses report a perception that their workloads

are unmanageable.
Having a nurse with the demands of an increased workload may also detract from time to

properly review orders, as well as administer medication safely (Fahrenkopf et al., 2007). In

addition, high workloads contribute to faster task completion and error rates (e.g., medication

administration errors) as the workload increases (Kohn et al. 2000). In addition, distractions and

interruptions created by the high workload can also contribute to a medication error (Westbrook

et al.,2010).

Workload causes many medication administration errors among pediatric nurses leading to

fatigue and stress. In Europe, 20% or more MEs because of heavy workload combined with the

shortage of healthcare personnel (ECAMET, 2022). Area of High Workload and Stress One

common, glaring issue that affects the well-being of healthcare professionals is mental health

with this coinciding with a strenuous burden for nursing(units). Nurses may experience cognitive

stress, fatigue, and emotional strain due to the high mental workload that results from heavy

work demands with limited resources. The principal components that can lead to job stress are

long working hours, low support, and insufficient sleep which may affect physical and mental

health as centralized factors for the provision of qualified care.

Higher workloads may have detrimental effects on the mental health of nurses, including stress

(Aiken et al., 2002), burnout, and emotional exhaustion. Studies have shown an eventual

increase in the levels of anxiety and depression with a higher workload for nurses. Further, the

chronic stress associated with increased workload can distract attention and limit cognitive

function which increases error susceptibility in nurses (Poghosyan et al., 2010). In particular, job

dissatisfaction as a result of heavy workloads may drive further downstream mental health issues

for nurses that can foster medication errors in return (Griffiths et al., 2009).
More than 1 in 10 nurses who suffer from mental and psychosocial health disorders have been

involved in MEs resulting in ADE with serious consequences for patients ( particularly pediatric

patients), mainly during the COVID-19 pandemic (European Biosafety Network, 2022).

Overcrowded ward, staffing, and workflow interruptions

ME rates in the United States were higher with emergency department volume on a person-hours

basis, indicating that a high pace of work is associated with risk. Kulstad et al. In an over-

crowded ED of a large hospital, (Kulstad et al., 2010) observed 6728 medication administration

procedures and reported 283 MAEs. The errors include: (administering medications at wrong

doses, frequencies, durations, or by the incorrect route; administering a medication that is

contraindicated to the patient & each testament off-base-medication)

An increase in the crowd/workload of the ward could lead to increased risk factors for

medication administration errors, from the nursing side. In one study, overcrowding was

positively correlated with patient acuity and complexity which results in overworked nurses

handling more complex medication regimens simultaneously (Blegen et al., 2007). An

overcrowded ward can leave nurses feeling rushed and under pressure to work more quickly

contributing to the increase in medication errors (Westbrook et al., 2010). Moreover,

overcrowded wards are associated with more noise at the ward. That could be in terms of

telephone call requests or walking nurses to take oral medications for patients which may disrupt

another nurse’s concentration and distract attention from medication administration detail.

Short staffing in nursing is a major cause of medication errors. Several studies have suggested

that the presence of lower nurse staffing levels could contribute to a heavier workload, fatigue,
and stress among nurses; which in turn may be related to medical errors during administration of

medications into patients. Inadequate staffing has been linked to nurses feeling overwhelmed

resulting in increased medication errors with drug omissions, delays of dosing on time, poor pain

control as well errors related to Medications. Furthermore, insufficient staffing can lead to

diminished quality of care with delays or omissions in individual patient tasks (eg,

communication with the patients, skin and oral hygiene). In Michigan, USA over 90% of nurses

interviewed reported the associated risk with MEs cited as understaffing (Michigan Nurses

Association). Nearly twice as many nurses now witness patient death as a result of tasking too

many patients, 42% in 2023 up from just 22% for the year.

Hughes and Lapane (2006) further showed the links between short staffing with medication

error, emphasizing that nurses in many instances have an overwhelming workload due to

inadequate staffing levels. This strain prevented them from methodically checking a medicine

order and its administration for safety sustain. Nurses overburdened with patient care workloads

are called to skip or rush through some of the steps in providing safe high-quality nursing

services, which increases the chances of committing errors. More specifically, where the

pressures are higher, the environment is noisy and chaotic, and there’s less use of resources, it

forces nurses to take shortcuts because they are mostly just trying to do the best they can in these

circumstances (Alomari et al.,2017). According to the prior study on understaffing and its effect,

it further affected patient care quality. Using staff examples, they describe how understaffing

affects the sorts of medication administration tasks nurses do and how patients are placed at risk

for harm in less-than-thorough processes. Nurses may be left with very little time per patient as

their case continues to rise, potentially leading existent medication errors for each of the patients

they care.
Nursing tasks and the nature of workflow interruption, are known as frequent stressors in nurse

work which their distracted attention may lead to Medication errors (Tschannen et al.,2011)

frequent workflow barriers identified communications systems - pagers, landlines & traditional

handwritten prescription orders long orders set limited interaction between the healthcare team.

According to Baker et al., 2018), when the cognitive process of nurses is interrupted they cannot

focus on the Medication administration tasks that they are performing. Stating that frequent

interruptions in the nursing task like constant paging, interruptions from colleagues asking for

assistance, and unprecedented alarms. Similarly, Westbrook et al.,2010 explored the impact of

workflow interruptions on medication safety. Interruptions in medication administration have

been linked to a higher probability of errors made by nurses, especially where workload and time

constraints are involved. This illustrates the challenge of interruptions that constrain the carefully

designed stages for administering medication. the potential errors in drug dose and timing with

common deviations from established protocols to administer medications as intended. Fragments

of nurses' workflow are interrupted causing them to lose track and miss out on important steps

during any medication administration. The cumulative impact of frequent interruptions impairs

nurses' situational awareness and leads to error that compromises patient safety.

[Link] Nurses’ Factors

Attitude is a major factor in pediatric nursing, and with the wrong attitude medication errors can

easily occur. 96.2% of pediatric nurses in a study said that poor medication knowledge is the

cause of more medical errors, which means they have little confidence or understanding about

how to administer children's medicine (Milidina et al.,2016). Pediatric nurses with poor

calculation skills can be more prone to medication errors. The improper administration of

medications may result from incorrectly calculating drug dosages. Studies have shown that a
significant number of nurses do not possess the necessary mathematical skills to accurately

calculate doses (Ndosi & Newell, 2007). Which can have potentially dangerous adverse effects,

under treatment or over-dosing. Practically 73.58% of pediatric nurses reported poor calculation

skills as the cause of medication error (Milidinia et al.,2016). Several medications do not have

pediatric adaptations, thus demanding modifications of adult dosages by the nurse are potential

steps where errors could occur. Since pediatric-specific parenteral medications are generally not

available, adult formulations at high concentrations must be used for the administration process

(Harada et al., 2012). Murphy and While (2012) also point out the problem of incorrectly

formulated prescriptions, in which drug manipulation can result in incorrect dosages as well as

have an adverse effect due to potential contamination.

Certainly, one large contributing factor is the lack of training in pediatric pharmacotherapy.

Nurses need to be continually educated and trained in the complexities of administering pediatric

medications. Harada et al. Pediatric medication error studies have shown high published rates of

administration errors (72-75%) in pediatric wards highlighting the need for more education and

training relating to specialization with pediatrics over general work rotation. Kaushal et al.

(2001) reinforced this point and advocated ongoing multidisciplinary research with root-cause

analysis to improve medical-system safety.

2.4.2 Environmental Causes

Poor lighting in healthcare settings can lead to medication errors in pediatric nursing by

impairing nurses' ability to accurately read medication labels, dosage instructions, and patient

records. Inadequate lighting can cause eye strain and reduce visual acuity, increasing the

likelihood of mistakes during medication preparation and administration (Schettino et al., 2011).

Ensuring sufficient and appropriate lighting in medication preparation areas is essential to

the stability and efficacy of medications, leading to potential errors in pediatric nursing. Certain

medications require specific storage conditions to maintain their potency, and deviations from

these conditions can result in compromised medication quality (World Health Organization,

2015). Additionally, extreme temperatures can cause discomfort and distract nurses, impacting

their focus and accuracy during medication administration. poor use of space in healthcare

settings can lead to medication errors by creating obstacles and distractions for nurses. Crowded

or cluttered workspaces can hinder efficient workflow, increase the time needed to locate

medications and raise the risk of administering the wrong drug or dosage (Patterson et al., 2012).

Optimizing the layout to streamline processes and reduce physical barriers is crucial for

minimizing errors and enhancing patient safety. Disorganized medication storage and

administration areas can be a factor that leads to errors by making it difficult for nurses to find

and correctly identify the needed medications. Mixing different drugs or failing to label them

clearly can lead to confusion and mistakes (Institute for Safe Medication Practices, 2014).

Implementing systematic organization, proper labelling, and regular audits of medication storage

areas can help mitigate these risks and ensure safe medication practices. Look-alike or sound-

alike drugs in pediatric nursing increase the risk of mix-ups. Medications with similar names or

appearances can be easily confused, especially in high-pressure situations, leading to the

administration of the wrong drug or dosage (Lambert et al., 2016). Implementing strategies such

as tall man lettering, color-coding, and thorough staff training can help distinguish these

medications and reduce the likelihood of errors. Physical aspects of the environment (lighting,

temperature, noise) can potentially increase the number of MEs by creating stress in nursing staff

(Kaboodmehri et al.,2019).
Systemic problems in healthcare, such as inadequate communication channels, lack of

standardized protocols, and insufficient training, can lead to medication errors in pediatric

nursing. These systemic issues can create an environment where critical information about

medications, patient conditions, or treatment plans is poorly conveyed or misunderstood. For

instance, fragmented communication during shift changes can result in vital details being

overlooked, while inconsistent protocols may confuse proper medication procedures.

Additionally, if nurses do not receive continuous education on best practices and emerging

medication guidelines, their ability to safely administer drugs diminishes. Addressing these

systemic problems is essential to reduce medication errors and enhance the overall safety and

quality of pediatric care

Organizational factors

Organizational causes of medication errors refer to system-level factors within healthcare

institutions that contribute to mistakes in prescribing, dispensing, and administering medications.

These causes include inadequate staffing and high nurse-to-patient ratios, which lead to

overburdened healthcare workers and increased risk of errors. Poor communication among

healthcare providers, particularly during transitions or handoffs, is another organizational issue

that can result in miscommunication of critical medication information. The lack of standardized

protocols, such as medication administration guidelines, further increases the likelihood of

mistakes. Additionally, insufficient access to technological support, such as computerized

physician order entry (CPOE) systems, and the absence of clinical pharmacists in patient care

teams contribute to errors by limiting oversight and real-time error detection. These

organizational flaws create environments where human errors are more likely to occur,

especially in high-risk populations like pediatric patients.

inadequate nurse staffing, which leads to high nurse-to-patient ratios. Nurses are primarily

responsible for administering medications, and when they are assigned too many patients, their

ability to focus and double-check medication dosages is compromised. Stratton et al., (2004)

found that distractions and interruptions, exacerbated by high nurse-patient ratios, were

significant reasons for medication errors in pediatric units. In their study, pediatric nurses

reported a higher incidence of errors compared to adult units, with high workloads being a major

factor (Stratton et al., 2004). Furthermore, Baraki et al., (2018) identified that hospitals with

lower nurse-to-patient ratios experienced more medication errors, particularly because

overburdened nurses are more prone to calculation mistakes in pediatric drug dosing.

The availability of appropriate facilities and resources for medication preparation is another

critical organizational factor influencing medication errors. Many hospitals lack dedicated

medication preparation rooms, which are essential for ensuring accuracy in medication dosing.

Baraki et al., (2018) reported that medications prepared in facilities without dedicated rooms

were significantly more likely to result in errors. Inadequate resources such as medication

administration guides and dosage calculators further exacerbate the issue, leading to incorrect

medication preparation and administration. Given that pediatric patients often require precise

medication dosages based on weight, the absence of these critical resources significantly

increases the likelihood of errors.

Another key organizational issue that contributes to medication errors is the presence of similar

drug names and patient names, which can easily be confused during the administration process.

This problem is particularly common in busy hospital environments where multiple patients are
being treated simultaneously. Studies have shown that similar-sounding or similarly spelled drug

names can lead to mix-ups, resulting in the wrong medication being administered to patients

(Institute for Safe Medication Practices, 2016). Additionally, when multiple patients have similar

names, healthcare workers may accidentally administer the wrong drug to the wrong patient,

especially when there are no strict protocols in place to verify patient identity (Smeulers et al.,

2015).

The absence of standardized medication administration protocols is another organizational factor

contributing to errors in pediatric medication management. Hospitals that lack clear guidelines

and checklists for healthcare providers face higher rates of medication errors. For instance,

Baraki et al. (2018) found that hospitals without established protocols for medication

administration had a significantly higher occurrence of errors. When protocols such as "five

rights" (right patient, right drug, right dose, right route, right time) are not rigorously enforced,

the likelihood of mistakes increases dramatically (Smeulers et al., 2015). The absence of such

protocols particularly affects pediatric patients, who are more vulnerable to errors due to weight-

based dosing and other complexities.

Long working hours and mandatory overtime are additional organizational factors contributing

to medication errors. Fatigue from extended shifts impairs the cognitive function of healthcare

professionals, making them more susceptible to mistakes. Stratton et al., (2004) found that long

shifts and overtime were commonly cited by nurses as factors contributing to medication

administration errors. The impact of fatigue on nurses' performance is well-documented, as

extended work hours lead to diminished concentration, reduced attention to detail, and a higher
likelihood of neglecting critical steps such as double-checking medication doses or ensuring that

the right drug is administered at the correct time (Ball et al., 2016).

Effective communication among healthcare providers—nurses, physicians, and pharmacists—is

essential for preventing medication errors. Poor communication is a pervasive organizational

issue that often leads to errors, particularly during the medication ordering and administration

stages. Fortescue et al., (2003) emphasized the importance of improving communication between

healthcare professionals as a key strategy for preventing medication errors. Miscommunication

or lack of collaboration among team members can result in incorrect dosage orders, improper

medication administration routes, or delays in providing critical drugs. For instance, errors

frequently occur during shift changes when critical information is not properly relayed,

increasing the risk of medication administration errors (Riesenberg et al., 2010).

The absence or limited use of technological solutions, such as computerized physician order

entry (CPOE) systems and clinical decision support systems (CDSS), is another significant

organizational factor leading to medication errors. Technological tools like CPOE help to

automate and streamline the medication ordering process, reducing the chances of human error.

Fortescue et al., (2003) noted that implementing CPOE with decision support could prevent a

significant portion of medication errors by alerting clinicians to potential drug interactions,

dosage errors, or allergies. Despite the benefits, many pediatric hospitals, particularly in low-

resource settings, either lack these systems or fail to utilize them effectively, leading to a reliance

on manual processes that increase the risk of errors (Kaushal et al., 2001).

The involvement of clinical pharmacists in healthcare teams is an effective strategy for reducing

medication errors, yet many pediatric hospitals lack this organizational support. Clinical
pharmacists play a crucial role in reviewing medication orders, identifying potential drug

interactions, and ensuring proper dosing, particularly in complex pediatric cases involving

multiple medications. According to Fortescue et al., (2003), having clinical pharmacists actively

participate in patient rounds and monitor medication processes could prevent up to 81% of

medication errors. The absence of ward-based clinical pharmacists in many hospitals leaves

nurses and physicians without the necessary oversight, increasing the risk of errors, particularly

in pediatric units where drug dosing is more complex.

2.5 IMPACT ON PATIENT/OUTCOME

2.5.1 Short-Term Effects

Research suggests that ME rates in children are much higher than those reported for adults, with

some studies indicating nearly two to three-fold higher numbers of cases per thousand and fewer

errors overall (Neuspiel & Taylor, 2023). Mistaken Interpretation (Whether incorrect based on

weight and/or age of the child) most common form of complaint reported as well most likely

occurring in a pediatric setting (Mersha et al., 2023). Failure to provide medication or the

administration of incorrect medications and dosages might result in acute reactions such as mild

symptoms to life-threatening complications for pediatrics, errors can result in prolonged hospital

stays due to error-related morbidities leading healthcare services with additional costs and

stresses on resources (Mersha et al., 2023). Medication errors can cause anxiety and distress for

families, especially if the child is harmed. This strain may influence the health of both the family

as a whole and its relationships with the healthcare providers (particularly the nurses) (Neuspiel

& Taylor, 2023). At their most severe, medication errors can cause fatalities, especially among
children (infants and neonates) and those with complicated health problems. For example, a

study observed deaths attributed specifically to dosing errors among pediatric patients (Kaushal

et al., 2001; Oshikoya et al.,2013).

2.5.2 Long Term Effects

This frequently results in increased healthcare consumption as children experiencing medication

errors often need supplementary medical interventions. The financial cost of adding frequent

hospitalizations, further therapies, and extended inpatient admissions places an extra burden on

families (Kohn et al.,2000). According to Feyissa et al. There may be additional medical care

required due to medication errors, leading to a more complex management of overall health in

the child. Medication errors can alter the developmental course of children in important ways.

Errors that impact neurological or physical development can result in functional impairments

yielding long-term educational and social disabilities. Severe medication errors capable of

causing cognitive and impaired socialization can result in lower health-related quality of life or

educational function (Oshikoya et al.,2013).

Feyissa et al.,2020 also drew attention to the psychological burden on families that may live in

fear for their child's health, the effect of MEs on children can be long-lasting throughout their

development and growth, and parents may feel anxiety, depression and helplessness about their

children’s health. The introduction of medication errors acts as a breach of, trust between

healthcare providers and families and also adds to stress and anxiety within the family (Kohn et

al.,2001). Economic burden of medication errors on patients, nurses, and hospitals There are

limited studies done to completely assess the economic burdens of these errors in pediatric

healthcare settings. When it comes to pediatric medication, errors can burden the finances of
patients, nurses, and hospitals. left unmanaged, these errors will accumulate into more expensive

care through additional treatments, longer time in hospital, and even legal suits.

[Link] Economic impact on patients, nurses and hospitals

Medication errors in pediatric settings cause patients and their families to incur increased

medical expenses. These charges may come from the cost of extra therapies and extended

lengths in hospitals. For example, the expense of treating a preventable adverse drug event

(ADE) in American community hospitals can be up to €6314.35 per incident (Walsh et al.,2017).

For families who lack sufficient insurance protection, these costs can bankrupt them.

Medication errors lead to added tasks and emotional burdens on the nursing staff. These errors

force nurses to spend more time dealing with the fallout when a mistake occurs, making them

less productive and increasing labor costs for hospitals. In addition, the psychological toll of

committing medication errors can result in burnout which damages the quality of care and leads

staff to a high turnover rate (Rinke et al.,2014).

Medication Errors are costly for Hospitals to address, these costs include tangible ones such as

additional treatments and longer patient stays, but also intangible methods - potential legal

settlements in addition to potentially increased insurance premiums. A study, for instance,

indicated €2184.93 per error among hospital inpatients on medication errors (Walsh et al.,2017).

Hospitals can also face reputational damage, which then erodes patient confidence and lowers

future footfalls (footfalls lead to business, as after all it is a commodity), thus ensuring revenue

hits.
2.6 Strategies to Mitigate Medication Errors in Children

Medication errors in pediatric patients show the serious potential risk that not only shows

physiological pain/effects but manifests in the social, emotional, and economic aspects of all

individuals involved in the errors ( Patients, nurses, and hospitals). Medication errors can be

curtailed with the use of advanced technologies and Education besides implementing better

processes.

2.6.1 Process Improvements

Adherence to standardized medication administration procedures can dramatically decrease

errors. This includes having a second healthcare provider go over medication orders, utilizing

checklists, and ensuring clear communication between all staff members involved. Also

important is creating a culture of safety in which staff can feel free to report errors without fear

of retribution. This process can aid in identifying systemic issues and also prevent future

mistakes (Walsh et al., 2017; Rinke et al, 2014).

2.6.2 Technological Adoption

Technological aids, such as Computerized Physician Order Entry (CPOE) systems and barcoding

for medication administration have each been found beneficial in reducing prescribing or

dispensing errors. The CPOE systems order entry for the physician and in turn, minimizes

transcription errors, additionally provides clinical decision support to comprehend patient drug

allergens which barcoding requests ask that can improve results by ensuring correct medication

is administered to the right patients. Although expensive to implement initially, previously

reported studies have shown substantial decreases in errors using these technologies (Rinke et

al.2014). One of the most effective strategies for reducing medication errors in pediatric patients
is the implementation of CPOE systems with integrated clinical decision support systems

(CDSS). According to Fortescue et al. (2003), CPOE could prevent 72.7% of all medication

errors and 75.8% of potentially harmful errors in pediatric inpatients. CPOE ensures that

medication orders are legible and complete while CDSS adds checks related to drug doses,

routes, and frequencies (Fortescue et al., 2003). This system is particularly beneficial for

pediatric patients, who often require weight-based dosing, which can be error-prone. By

automating calculations and flagging potential issues, CPOE significantly reduces the risk of

errors such as 10-fold dosing mistakes, which are common in pediatric settings. In addition,

technology-driven solutions such as smart infusion pumps are a significant contributor to

medication error reduction. These pumps have inbuilt safety features such as drug libraries and

dose limits that prevent medication delivery by infusion at the wrong rate (Marufu et al., 2021).

Manrique-Rodríguez et al. study reported an overall alert performance of 92% for user

programming errors with 49% of the failures having the potential to cause moderate to severe

harm (Marufu et al., 2021). Smart infusion technology addresses the high risks of administering

intravenous medications to infants and children in pediatric and neonatal intensive care units.

2.6.3 Staff training and awareness programs

Nursing interventions are crucial for reducing medication administration errors, as nurses are the

final checkpoint before a drug reaches a patient. Educational programs for nurses, focusing on

medication safety, have proven effective in reducing errors. Marufu et al. (2021) conducted a

meta-analysis showing that educational interventions reduced medication errors by 64% (Marufu

et al., 2021). These programs often include training on proper drug calculations, administration

techniques, and strategies to prevent interruptions during medication administration. Simulation-

based education has been particularly successful in preparing nurses to handle complex
medication processes in pediatric settings, leading to a reduction in errors related to incorrect

drug preparation and administration. Improved communication between healthcare providers is

another critical strategy for reducing medication errors. In pediatric settings, where care is often

multidisciplinary, this ensures that all team members—physicians, nurses, and pharmacists—are

aligned is essential for preventing errors. Fortescue et al. (2003) stated that more efficient

communication between physicians, nurses, and pharmacists could prevent 85.8% of potentially

harmful medication errors. Structured communication tools, such as detailed checklists

containing patient information and standardized handoff procedures, ensure that all relevant

information is shared among team members, reducing the risk of omissions or misunderstandings

that could lead to errors (Marufu et al., 2021).