Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis.

Matthew D Jones; Jonathan Clarke; Calandra Feather; Bryony Dean Franklin; Ruchi Sinha; Ian Maconochie; Ara Darzi; Nicholas Appelbaum

Study

Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis.

February 23, 2022

Jones MD, Clarke J, Feather C, et al. Ann Pharmacother. 2021;55(11):1333-1340.

View more articles from the same authors.

Medication errors during pediatric resuscitation are common. Using video recordings of simulated pediatric resuscitations, the researchers explored deviations in care related to the delivery of intravenous medicine. Findings suggest that deviations play a crucial role in intravenous medication administration errors, and deviations were more likely to occur during the use of an online injectable medicine guideline.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis.

December 18, 2019

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.

April 5, 2023

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

November 16, 2022

Outcomes of medication misadventure among people with cognitive impairment or dementia: a systematic review and meta-analysis.

July 21, 2021

The impact of electronic health record interoperability on safety and quality of care in high-income countries: systematic review.

October 5, 2022

The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis.

February 23, 2022

Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems.

July 31, 2019

The contribution of staffing to medication administration errors: a text mining analysis of incident report data.

December 18, 2019

Preventing home medication administration errors.

March 14, 2022

Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients.

June 9, 2021

Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective observational study.

March 18, 2020

Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data.

July 27, 2022

The devil is in the detail: how a closed-loop documentation system for IV infusion administration contributes to and compromises patient safety.

July 22, 2020

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review.

April 20, 2022

Use and impact of virtual primary care on quality and safety: the public's perspectives during the COVID-19 pandemic.

January 12, 2022

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Implementation of a discharge education program to improve transitions of care for patients at high risk of medication errors.

February 19, 2020

Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health.

August 16, 2017

An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.

March 1, 2023

A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies.

January 25, 2023

Experiences and perspectives of transgender youths in accessing health care: a systematic review.

August 4, 2021

Comparative performance of pediatric weight estimation techniques: a human factor errors analysis.

November 1, 2017

How can patient-held lists of medication enhance patient safety? A mixed-methods study with a focus on user experience.

February 5, 2020

Exploring the role of guidelines in contributing to medication errors: a descriptive analysis of national patient safety incident data.

February 21, 2024

To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.

February 16, 2022

Patient errors in use of injectable antidiabetic medications: a need for improved clinic-based education.

November 4, 2020

Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.

October 28, 2020

Medication histories in critically ill patients completed by pharmacy personnel.

August 7, 2019

Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.

October 14, 2020

Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews.

February 10, 2021

Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy.

November 17, 2021

Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis.

March 8, 2023

Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis.

January 12, 2022

Delay or avoidance of medical care because of COVID-19-related concerns--United States, June 2020.

October 7, 2020

Alert burden in pediatric hospitals: a cross-sectional analysis of six academic pediatric health systems using novel metrics.

November 3, 2021

Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.

March 30, 2022

Parent participation in morbidity and mortality review: parent and physician perspectives.

June 22, 2022

Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program.

November 11, 2015

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis.

February 3, 2021

Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis.

December 14, 2022

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project.

April 27, 2016

Methods used to obtain pediatric patient weights, their accuracy and associated drug dosing errors in 142 simulated prehospital pediatric patient encounters.

August 25, 2021

Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department.

May 25, 2022

Quest for the ideal: a redesign of the medication use system.

January 31, 2007

Reliability and usability of a 7-minute chart review tool to identify pediatric prehospital adverse safety events.

August 1, 2018

Systematic review of the impact of physician implicit racial bias on clinical decision making.

May 5, 2017

Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis.

July 8, 2020

Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.

June 24, 2020

Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.

April 11, 2012

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system.

February 2, 2022

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.

January 15, 2020

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion.

December 2, 2020

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.

June 16, 2021

Long-term care healthcare-associated infections in 2021: an analysis of 17,971 reports.

July 13, 2022

Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review.

September 29, 2021

Analysis of iatrogenic and in-hospital medication errors reported to United States poison centers: a retrospective observational study.

June 24, 2020

Medicines reconciliation in the emergency department: important prescribing discrepancies between the shared medication record and patients' actual use of medication.

March 16, 2022

Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis.

March 10, 2021

Effect of a mobile app on prehospital medication errors during simulated pediatric resuscitation: a randomized clinical trial.

September 15, 2021

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data.

December 21, 2022

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

January 16, 2013

Impact of medication reviews on potentially inappropriate medications and associated costs among older women in aged care.

September 21, 2022

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.

August 19, 2020

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Identification of adverse events in ground transport emergency medical services.

September 14, 2011

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

July 19, 2017

Treatment patterns and clinical outcomes after the introduction of the Medicare Sepsis Performance Measure (SEP-1).

May 5, 2021

Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database.

October 14, 2020

The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England.

August 18, 2021

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals.

October 14, 2020

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis.

December 2, 2020

The incidence and nature of prescribing and medication administration errors in paediatric inpatients.

February 24, 2010

Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions.

September 2, 2009

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies.

May 25, 2022

Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations.

October 27, 2021

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey.

March 10, 2021

Effect of Patient and Family Centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions.

March 8, 2023

Perceptions of chief clinical information officers on the state of electronic health records systems interoperability in NHS England: a qualitative interview study.

September 27, 2023

Human factors analysis of latent safety threats in a pediatric critical care unit.

May 18, 2022

Duplicate medication order errors: safety gaps and recommendations for improvement.

October 12, 2022

Applying decision science to the prioritization of healthcare-associated infection initiatives.

October 27, 2021

Improved medication management with introduction of a perioperative and prescribing pharmacist service.

August 12, 2020

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Defining and studying errors in surgical care: a systematic review.

August 17, 2022

Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals.

June 29, 2022

Pediatric surgical errors: a systematic scoping review.

July 20, 2022

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

January 12, 2022

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

May 14, 2014

Electronic diagnostic support in emergency physician triage: qualitative study with thematic analysis of interviews.

November 16, 2022

Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis.

May 19, 2021

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Related Resources

WebM&M Cases

Verbal Orders and Medication Overrides: A Dangerous Combination

April 24, 2024

Examining the relationship between nurse fatigue, alertness, and medication errors.

April 3, 2024

Safety and Human Performance in the Operating Room and Other Extreme Environments.

March 27, 2024

An mHealth design to promote medication safety in children with medical complexity.

March 20, 2024

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

February 14, 2024

WebM&M Cases

Medication Mix-Up Leads to Patient Death

November 30, 2023

Battling alarm fatigue in the pediatric intensive care unit.

October 11, 2023

Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety.

September 6, 2023

Anticoagulation-associated adverse drug events in hospitalized patients across two time periods.

July 26, 2023

Evaluation of detected medication errors within the operating room at an academic medical center.

June 21, 2023

The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study.

June 14, 2023

Prescribing errors in children: why they happen and how to prevent them.

June 14, 2023

Classification of health information technology safety events in a pediatric tertiary care hospital.

June 7, 2023

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

May 3, 2023

Effect of a hospital command centre on patient safety: an interrupted time series study.

April 26, 2023

STAMP: a 5-year project to reduce paediatric prescribing errors.

April 19, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Safety considerations for challenges when using smart infusion pumps.

November 2, 2022

Resident and nurse perspectives on the use of secure text messaging systems.

October 19, 2022

A systematic review of nursing practice workarounds.

October 19, 2022

Intravenous smart pumps at the point of care: a descriptive, observational study.

October 12, 2022

Exploring care left undone in pediatric nursing.

September 28, 2022

Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents.

September 14, 2022

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

Association between language use and ICU transfer and serious adverse events in hospitalized pediatric patients who experience rapid response activation.

August 17, 2022

Patient safety informatics: meeting the challenges of emerging digital health.

July 20, 2022

Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.

June 22, 2022

See More About The Topic

Hospitals

Information Professionals

Pediatrics

Critical Care Nursing

Administration Errors

Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site