Evaluation of Medication Dose Alerts in Pediatric Inpatients

A categorization of alerts generated from inpatient orders at a medium-sized pediatric hospital in 2010 using a vendor-provided computerized provider order entry software with a custom-developed set of 13,530 alerts, 89% of which were maximum-dose alerts. Over the year of data collection there were 182,308 orders for 1092 medications. 6.1% of orders produced an alert. 73.4% of those were dose-range alerts, which users complied with only 8.5% of the time. Overall, providers disregarded 92.4% of alerts of all types.

Scharnweber 2013 (Link) (Int J Med Inform) | PubMed 23643148 | Author Search

Pediatric Weight Errors and Resultant Medication Dosing Errors in the Emergency Department

A retrospective study of 79,000 ED encounters at a children’s hospital and two general hospitals. The intent of the study was to characterize the frequency of weight errors and to determine of the children’s hospital was any better at correcting errors than the general hospitals. The findings were that weight errors were uncommon (0.63% of all weights, as defined by the weight being a new extreme value on the growth chart) in the 3 EDs, but they led to identifiable weight-based medication-dosing errors with the potential to cause harm. The rates of error where similar across hospitals, and it looked like the children’s hospital was slightly better at intercepting errors once they were committed. Common weight errors included the weight in pounds being substituted for the weight in kilograms and decimal placement errors.

Hirata 2017 (Link) | PubMed 28976456 | Author Search

Tenfold Medication Errors: 5 Years’ Experience at a University-Affiliated Pediatric Hospital

A study of pediatric inpatient safety reports. From the abstract: “From 6643 medication-related safety reports, 252 10-fold medication errors were identified at a mean reporting rate of 0.062 per 100 total patient days. Morphine was the most frequently reported medication, and opioids were the most frequently reported drug class. Twenty-two reports described patient harm. Intravenous formulations, paper ordering, and drug-delivery pumps were frequent error enablers. Errors of dose calculation, documentation of decimal points, and confusion with zeroes were frequent contributing causes to 10-fold medication error.”

Doherty 2012 (Pediatrics) | PubMed 22473367 | Author Search

Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics

Prehosp Emerg Care. 2017;21:185-191.

This survey of paramedics found that pediatric dosing errors in the prehospital period are common. Respondents used varied methods for estimating weight of pediatric patients in order to calculate drug doses, and they advocated for pediatric training and standardized weight estimation methods to reduce risks. These findings suggest several possible interventions to enhance pediatric medication safety in the prehospital setting.

| PubMed 28257249 | Author Search

Prescription Order Risk Factors for Pediatric Dosing Alerts

International Journal of Medical Informatics


A retrospective analysis of inpatient medication orders and dosing alerts at a large, academic, pediatric medical center. Pediatric orders had higher odds for an alert compared to adult orders. The alert rate was highest for immunosuppressive agents (> 50% alert rate), medications for neonates (6.7%), orders for rectal administration (9.5%), and orders for continuous infusion (7.9%). Orders for albuterol continuous aerosol and heparin injection solution had near-100% alert rates. Opioid alerts had among the lowest alert rates, at 7.4%. There was also a temporal analysis that indicated that January was

Stultz 2015 (Link) | PubMed 25466381 | Author Search

Computerized Dose Range Checking Using Hard and Soft Stop Alerts Reduces Prescribing Errors in a Pediatric Intensive Care Unit

This before-and-after study found that introduction of a tiered alert system for medication dosages in pediatric patients led to an increase in alerts, but also resulted in fewer overridden alerts and more medication order revisions. This work emphasizes the need to improve electronic medication alerts to make them more actionable and reduce alert fatigue. (Journal of Patient Safety)

Balasuriya 2014 (Link) | PubMed 25370855 | Author Search