Peer-reviewed article
Factors associated with medication administration errors in hospitalized pediatric patients: A scoping review.
Motta Robayo CL, Martínez Pinto J, Tabango Goyes B, Varela Chagüendo L, Duque Grisales E et al. ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This scoping review examined the causes of medication administration errors in hospitalized children aged 0 to 18 years across 25 studies. Incorrect dosing was the most common type of error, with neonates and infants at highest risk, particularly in intensive care units. Human factors like knowledge gaps were the main contributors, though errors also occurred frequently on general wards. The review identified five strategies to prevent these errors: staff education, double-checking procedures, safe reporting systems, technology solutions, and better communication between healthcare professionals.
Key points
- Incorrect dosing was the most prevalent medication error type, identified in 18 of 25 studies (72%)
- Neonates and infants were the most vulnerable age groups; PICU and NICU had highest error rates, but 37% of general ward administrations involved errors
- Knowledge deficits in healthcare staff were the most frequently reported human factor contributing to errors (13 studies, 52%)
- Five mitigation strategies identified: professional education, dual verification, unified non-punitive reporting, technology, and interprofessional communication
- Medication errors in pediatric patients result from multiple interrelated human, environmental, communicative, and medication-related factors
Limitations
This scoping review synthesizes existing evidence rather than providing new empirical data, and is limited to studies published in English, Spanish, or Portuguese. The review cannot determine the relative effectiveness of different prevention strategies or provide precise incidence rates of medication errors across all pediatric settings.
Abstract
Background Medication errors are a leading preventable cause of harm in hospitalized children. The pediatric population is particularly vulnerable due to weight-based dosing requirements, developmental pharmacokinetic variability, and limited capacity for self-advocacy. Objectives To map and synthesize the available evidence on factors associated with the occurrence of medication administration errors in hospitalized pediatric patients. Eligibility criteria Studies addressing administration phase medication errors (per the National Coordinating Council for Medication Error Reporting and Prevention, NCC MERP) in hospitalized children aged 0 to 18 years, published in English, Spanish, or Portuguese, using quantitative, qualitative, or mixed methods designs. Sources of evidence Nine electronic databases were searched from inception to July 2026 using English, Spanish, and Portuguese (DeCS) terms, supplemented by hand searching of reference lists. Charting methods The review followed the Joanna Briggs Institute (JBI) methodology; data were charted with the JBI standardized instrument and synthesized narratively with thematic analysis. Results Of 1,012 records, 25 studies met the inclusion criteria. Incorrect dosing was the most prevalent error type (18 studies, 72%). Neonates and infants were the most vulnerable group, and PICU and NICU the highest-risk settings, although a direct observation study reported that 37% of administrations on general wards involved an error. Human factors, particularly knowledge deficits, were the most frequently reported contributors (13 studies, 52%). Five complementary mitigation strategies were identified: professional education, dual verification, unified non-punitive reporting, technology, and interprofessional communication. Conclusions Medication administration errors in pediatric inpatients are driven by a multilayered interplay of human, environmental, communicative, and medication related factors. Effective prevention demands integrated, systems-based approaches combining education, technology, standardized protocols, and a non-punitive safety culture.