Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents.

Understanding how and when medication errors occur is necessary to implement medication management safety strategies. This study determined that most self-reported high-alert medication errors in a children’s hospital were associated with administration and prescribing. One-quarter of incidents included two to four errors, and wrong dose or omission were the most common. Systemic defenses are required to reduce wrong dose, omission, and documentation errors.