Prescribing errors in a pediatric emergency department.

Michael L. Rinke; Margaret Moon; John Clark; Shawna Mudd; Marlene R. Miller

Study

Prescribing errors in a pediatric emergency department.

March 5, 2008

Rinke ML, Moon M, Clark J, et al. Pediatr Emerg Care. 2008;24(1):1-8.

View more articles from the same authors.

Pediatric medication errors pose unique challenges, particularly around weight-based dosing. This study describes the types of prescribing errors discovered through retrospective chart review and highlights the error rates among different levels of trainees and providers.

PubMed citation

Available at

Related Resources From the Same Author(s)

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

April 18, 2007

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.

June 13, 2007

State-mandated hospital infection reporting is not associated with decreased pediatric health care–associated infections.

September 9, 2015

Pediatric antidepressant medication errors in a national error reporting database.

February 17, 2010

Decreasing errors in pediatric continuous intravenous infusions.

May 24, 2006

Medication errors in the ambulatory treatment of pediatric attention deficit hyperactivity disorder.

September 3, 2008

Patient safety rounds in a pediatric tertiary care center.

January 9, 2008

Interventions to reduce pediatric medication errors: a systematic review.

July 30, 2014

Transition from a traditional code team to a medical emergency team and categorization of cardiopulmonary arrests in a children's center.

February 20, 2008

Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.

March 6, 2005

Can teaching medical students to investigate medication errors change their attitudes towards patient safety?

February 16, 2011

Tracking progress in patient safety: an elusive target.

August 16, 2006

Transforming the morbidity and mortality conference to promote safety and quality in a PICU.

April 6, 2016

The morbidity and mortality conference in PICUs in the United States: a national survey.

September 24, 2014

Paying the piper: investing in infrastructure for patient safety.

June 4, 2008

Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture/laceration.

February 29, 2012

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

May 3, 2017

Computer based medication error reporting: insights and implications.

June 21, 2006

Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database.

July 29, 2009

Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.

January 25, 2006

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

Targeted chart review of pediatric patient safety events identified by the Agency for Healthcare Research and Quality's Patient Safety Indicators methodology.

January 3, 2007

The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit.

August 20, 2014

Engaging patients and family members in patient safety—the experience of the New York City Health and Hospitals Corporation.

April 15, 2005

Wrong site surgery near misses and actual occurrences.

August 26, 2009

Translating patient safety legislation into health care practice.

November 29, 2006

Potential medication dosing errors in outpatient pediatrics.

January 11, 2006

Epidemiology of and risk factors for harmful anti-infective medication errors in a pediatric hospital.

September 19, 2018

Diagnostic error in pediatrics: a narrative review.

March 23, 2022

Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.

July 15, 2020

Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research.

November 4, 2015

Getting surgery right.

September 12, 2007

Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.

February 8, 2012

The Armstrong Institute Resident/Fellow Scholars: a multispecialty curriculum to train future leaders in patient safety and quality improvement.

July 13, 2016

"Teach-back" from a patient's perspective.

March 2, 2016

The role for leaders of health care organizations in patient safety.

September 19, 2007

A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).

March 15, 2006

How communication "failed" or "saved the day": counterfactual accounts of medical errors.

February 3, 2021

The role of automation in complex system failures.

May 11, 2005

Measurement of quality and assurance of safety in the critically ill.

April 8, 2009

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

November 2, 2005

Health care consumers' inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania.

December 12, 2007

Cardiovascular medication errors in children.

July 22, 2009

A national profile of patient safety in U.S. hospitals.

March 6, 2005

Clinically missed cancer: how effectively can radiologists use computer-aided detection?

May 16, 2012

Hospital admissions due to adverse drug reactions: a report from the Boston Collaborative Drug Surveillance Program.

March 27, 2005

Medical emergency team calls in the radiology department: patient characteristics and outcomes.

March 14, 2012

Reducing the risk of adverse drug events in older adults.

April 17, 2013

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care.

February 7, 2007

Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations.

April 15, 2005

Disruptive physician behavior: the importance of recognition and intervention and its impact on patient safety.

May 16, 2018

Applying modern error theory to the problem of missed injuries in trauma.

April 2, 2008

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.

March 23, 2011

Sleep deprivation: implications for obstetric practice in the United States.

August 26, 2009

Attitudes and practices related to clinical alarms: a follow-up survey.

April 18, 2018

Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety.

May 28, 2008

Procedural safety in emergency care: a conceptual model and recommendations.

October 24, 2012

Risk models to improve safety of dispensing high-alert medications in community pharmacies.

November 7, 2012

Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic.

June 30, 2021

Sustaining reliability on accountability measures at the Johns Hopkins Hospital.

January 27, 2016

Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital.

December 4, 2013

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

May 6, 2009

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review.

February 1, 2023

Outcomes with overlapping surgery at a large academic medical center.

February 21, 2018

ISMP medication error report analysis.

April 21, 2010

ISMP medication error report analysis.

March 10, 2010

ISMP medication error report analysis.

May 12, 2010

Intimidation: practitioners speak up about this unresolved problem.

October 5, 2005

Unlabeled containers lead to patient's death.

July 13, 2005

Medication administration discrepancies persist despite electronic ordering.

November 28, 2007

Association of clinical nursing work environment with quality and safety in maternity care in the United States.

November 11, 2020

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

January 20, 2010

Patient safety and quality outcomes for ED patients admitted to alternative care area inpatient beds.

May 29, 2019

A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system.

November 14, 2012

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

April 15, 2009

Resident fatigue: is there a patient safety issue?

January 6, 2010

Relationship between nursing home safety culture and Joint Commission accreditation.

May 2, 2012

The medical emergency team system: a two hospital comparison.

February 27, 2008

Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000–2013.

July 22, 2015

A system analysis of a suboptimal surgical experience.

February 4, 2009

Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.

March 8, 2006

SAFER Care: improving caregiver comprehension of discharge instructions.

March 31, 2021

Effectiveness of computerized provider order entry with dose range checking on prescribing errors.

May 31, 2006

Interpersonal and organizational dynamics are key drivers of failure to rescue.

December 5, 2018

An electronic health record–based real-time analytics program for patient safety surveillance and improvement.

December 5, 2018

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Residency training in handoffs: a survey of program directors in psychiatry.

June 10, 2015

The relationship between safety culture and voluntary event reporting in a large regional ambulatory care group.

March 22, 2017

Disclosure and reporting of surgical complications: a double-edged sword?

August 18, 2010

Impact of electronic prescribing in a hospital setting: a process-focused evaluation.

August 27, 2008

Primary medication non-adherence: analysis of 195,930 electronic prescriptions.

February 17, 2010

Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.

January 21, 2015

Leadership oversight for patient safety programs: an essential element.

January 17, 2018

Patient mortality during unannounced accreditation surveys at US hospitals.

April 5, 2017

Opioid-prescribing patterns of emergency physicians and risk of long-term use.

March 1, 2017

Label design affects medication safety in an operating room crisis: a controlled simulation study.

April 1, 2015

The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

May 15, 2019

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict.

August 28, 2013

Success in hospital-acquired pressure ulcer prevention: a tale in two data sets.

December 12, 2018

Dissecting Leapfrog: how well do Leapfrog Safe Practices Scores correlate with Hospital Compare ratings and penalties, and how much do they matter?

March 29, 2017

Related Resources

WebM&M Cases

Verbal Orders and Medication Overrides: A Dangerous Combination

April 24, 2024

Journal Article

Study

Implicit bias and patient care: mitigating bias, preventing harm.

April 10, 2024

Journal Article

Study

Let us to the TWISST; Plan, Simulate, Study and Act.

April 10, 2024

Telemedicine vs telephone consultations and medication prescribing errors among referring physicians: a cluster randomized crossover trial.

March 13, 2024

WebM&M Cases

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose

October 31, 2023

Weight estimation for drug dose calculations in the prehospital setting - a systematic review.

September 6, 2023

Incidence and severity of medication reconciliation discrepancies in trauma patients.

August 16, 2023

Improving emergency medicine clinician awareness of prehospital-administered medications.

August 9, 2023

Clinician factors associated with delayed diagnosis of appendicitis.

July 5, 2023

In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative.

June 28, 2023

The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question.

June 28, 2023

Patient safety in emergency departments: a problem for health care systems? An international survey.

June 21, 2023

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.

February 22, 2023

Misdiagnosis in the emergency department: time for a system solution.

February 8, 2023

ER doctors misdiagnose patients with unusual symptoms.

January 18, 2023

Weight and size descriptors for drug dosing: too many options and too many errors.

January 11, 2023

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

WebM&M Cases

EMS Perils from Hospital Overcrowding

August 31, 2022

Emergency department adverse events detected using the emergency department trigger tool.

August 24, 2022

Decreasing misdiagnoses of urinary tract infections in a pediatric emergency department.

August 10, 2022

Reducing pediatric emergency department prescription errors.

June 22, 2022

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

May 25, 2022

April 27, 2022

Medication safety in the emergency department: a study of serious medication errors reported by 101 hospitals from 2011 to 2020.

March 30, 2022

Antibiotic prescribing errors in patients discharged from the pediatric emergency department.

March 30, 2022

Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review.

January 26, 2022

Adverse events and emergency department opioid prescriptions in adolescents.

June 30, 2021

Adverse drug event-related admissions to a pediatric emergency unit.

April 14, 2021

Misdiagnosis and failure to diagnose in emergency care: causes and empathy as a solution.

November 11, 2020

See More About The Topic

Emergency Departments

Emergency Medicine

Pediatric Emergency Medicine

Hospital Pharmacy

Ordering/Prescribing Errors

Prescribing errors in a pediatric emergency department.

Implicit bias and patient care: mitigating bias, preventing harm.

Let us to the TWISST; Plan, Simulate, Study and Act.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Prescribing errors in a pediatric emergency department.

Implicit bias and patient care: mitigating bias, preventing harm.

Let us to the TWISST; Plan, Simulate, Study and Act.

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