Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

Reaffirmed With Reference & Data Updates

This policy statement was reaffirmed in September 2023 with reference and data updates. New or updated references and datapoints are indicated in bold typeface. No other changes have been made to the text or content. The AAP would like to acknowledge Mohsen Saidinejad, MD, MS, MBA, FAAP, FACEP and Mark X. Cicero, MD, FAAP, FAAP, for these updates.

Despite a national focus on patient safety since the publication of the Institute of Medicine (now the National Academy of Medicine) report “To Err is Human” in 1999, medical errors remain a leading cause of morbidity and mortality across the United States.1  Medication errors are by far the most common type of medical error occurring in hospitalized patients,2  and the medication error rate in pediatric patients has been found to be as much as 3 times the rate in adult patients.3,4  Because many medication errors and adverse drug events (ADEs) are preventable,1  strategies to improve medication safety are an essential component of an overall approach to providing quality care to children.

The pediatric emergency care setting is recognized as a high-risk environment for medication errors because of a number of factors, including medically complex patients with multiple medications who are unknown to emergency department (ED) staff, a lack of standard pediatric drug dosing and formulations,5  weight-based dosing,6,7  verbal orders, a hectic environment with frequent interruptions,8  a lack of clinical pharmacists on the ED care team,9,10  inpatient boarding status,11  the use of information technology systems that lack pediatric safety features,12  and numerous transitions in care. In addition, the vast majority of pediatric patients seeking care in EDs are not seen in pediatric hospitals but rather in community hospitals, which may treat a low number of pediatric patients.13  Studies also outline the problem of medication errors in children in the prehospital setting. A study of 8 Michigan emergency medical services agencies revealed errors for commonly used medications, with up to one-third of medications being dosed incorrectly.14  Medication error rates reported from single institutions with dedicated pediatric EDs range from 10% to 31%,15,16  and in a study from a pediatric tertiary care center network, Shaw et al6  showed that medication errors accounted for almost 20% of all incident reports, with 13% of the medication errors causing patient harm. The authors of another study examined medication errors in children at 4 rural EDs in northern California and found an error rate of 39%, with 16% of these errors having the potential to cause harm.17  The following discussion adds to the broad topic of medication safety by introducing specific opportunities unique to pediatric patients within EDs to facilitate local intervention on the basis of institutional experience and resources.

A multidisciplinary expert panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics (AAP), through its Committee on Pediatric Emergency Medicine, to discuss challenges related to pediatric medication safety in the emergency setting. The panel included emergency care providers, nurses, pharmacists, electronic health record industry representatives, patient safety organization leaders, hospital accreditation organizations, and parents of children who suffered ADEs. The panel outlined numerous opportunities for improvement, including raising awareness of risks for emergency care providers, trainees, children, and their families; developing policies and processes that support improved pediatric medication safety; and implementing best practices to reduce pediatric ADEs. Specific strategies discussed by the panel, as well as recent advances in improving pediatric medication safety, are described.

Computerized Physician Order Entry

Historically, the majority of pediatric medication errors were associated with the ordering phase of the medication process. Specific risks related to pediatric weight- based dosing include not using the appropriate weight,6  performing medication calculations based on pounds instead of the recognized standard of kilograms,6  and making inappropriate calculations, including tenfold dosing errors.18 20  Childhood obesity introduces further opportunity for dosing error. In addition to the lack of science to guide medication dosing in patients with obesity,21  frequent underdosing22  is reported, and currently available resuscitation tools are commonly imprecise.23  Furthermore, there are limited opportunities for prescription monitoring or double-checking in the ED setting, and many times calculations are performed in the clinical area without input from a pharmacist.9  The implementation of computerized physician order entry (CPOE) and clinical decision support (CDS) with electronic prescribing have reduced many of these errors, because most CPOE systems obviate the need for simple dose calculation. However, CPOE systems have not fully eliminated medication errors. Commercial or independently developed CPOE systems may fail to address critical unique pediatric dosing requirements.12 ,24  Kilogram- only scales are recommended for obtaining weights, yet conversion to pounds either by the operator or electronic health record may introduce opportunity for error into the system. In addition, providers may override CDS, despite its proven success in reducing errors.16,25  Prescribers frequently choose to ignore or override CDS prescribing alerts, with reported override rates as high as 96%.26  Allowing for free text justification to override alerts for nonformulary drugs may introduce errors. The development of an override algorithm can help reduce user variability.27  As the use of CPOE increases, one can expect that millions of medication errors will be prevented.28  For EDs that do not use CPOE, preprinted medication order forms have been shown to significantly reduce medication errors in a variety of settings and serve as a low-cost substitute for CPOE.29 32 

Standardized Formulary

The Institute of Medicine (now the National Academy of Medicine) recommends development of medication dosage guidelines, formulations, labeling, and administration techniques for the pediatric emergency care setting.5  Unfortunately, there are currently no universally accepted, pediatric- specific standards with regard to dose suggestion and limits, and dosing guidelines and alerts found in CPOE are commonly provided by third-party vendors that supply platforms to both children’s and general hospitals. The development of a standard pediatric formulary, independent of an adult-focused system, can reduce opportunities for error by specifying limited concentrations and standard dosage of high-risk and frequently used medications, such as resuscitation medications, vasoactive infusions, narcotics, and antibiotics, as well as look-alike and sound-alike medications.33 ,34  A standard formulary will allow for consistent education during initial training and continuing medical education for emergency care providers, creating a consistent measure of provider competency.35  At least 1 large hospital organization has successfully implemented this type of change.36  In addition, the American Society of Health-System Pharmacists is working with the Food and Drug Administration to develop and implement national standardized concentrations for both intravenous and oral liquid medications.37 

ED Pharmacists

Currently, many medications are prepared and dispensed in the ED without pharmacist verification or preparation because many EDs lack consistent on-site pharmacist coverage.9,38  In a survey of pharmacists, 68% reported at least 8 hours of ED coverage on weekdays, but fewer than half of EDs see this support on weekends, with a drastic reduction in coverage during overnight and morning hours.39  The American College of Emergency Physicians (ACEP) supports the integration of pharmacists within the ED team, specifically recognizing the pediatric population as a high-risk group that may benefit from pharmacist presence.40  The Emergency Nurses Association (ENA) supports the role of the emergency nurse as well as pharmacy staff to efficiently complete the best possible medication history and reduce medication discrepencies.41,42  The American Society of Health-System Pharmacists suggests that ED pharmacists may help verify and prepare high- risk medications, be available to prepare and double-check dosing of medications during resuscitation, and provide valuable input in medication reconciliation, especially of medically complex children whose medications and dosing may be unknown to ED staff and who present without a medication list or portable emergency information form.43  Medically complex patients typify the difficulty with medication reconciliation, with an error rate of 21% in a tertiary care facility.44  In this study, no 1 source from the parent, pharmacy, and primary provider group was both available and appropriately sensitive or specific in completing medication reconciliation. Pharmacist-managed reconciliation has had a positive impact for admitted pediatric patients and may translate to the emergency setting.45,46  ED pharmacists can also help monitor for ADEs, provide drug information, and provide information regarding medication ingestions to both providers and patients and/or families.47 

Dedicated pharmacists can be integrated through various methods, such as hiring dedicated pharmacy staff for the ED,7  having these staff immediately available when consulted, or having remote telepharmacy review of medication orders by a central pharmacist.48,49  Although further research is needed on the potential outcomes on medication safety and return on investment when a pharmacist is placed in the ED, current experience reveals improvements in medication safety when a pharmacist is present.50  Studies from general EDs reveal significant cost savings as well,51  with the authors of 1 study in a single urban adult ED identifying more than $1 million dollars of cost avoidance in only 4 months.52 

Training in Pediatric Medication Safety

Dedicated training in pediatric medication safety is highly variable in the curricula of professional training programs in medical, nursing, and pharmacy schools.53  Although national guidelines support the training of prehospital personnel with specific pediatric content and safety and error-reduction training,54 ,55  a nearly 35% prehospital medication error rate for critical medications for pediatric patients remains.56  At the graduate medical education level, the curricula of pediatric and emergency medicine residency programs and pediatric emergency medicine fellowship programs do not define specific requirements for pediatric medication safety training.5759  The same is true for pharmacy programs.60  Although schools of pharmacy include pediatric topics in their core curricula, pediatric safety advocates believe there is an opportunity for enhanced and improved training.61 

Experts in pediatric emergency care from the multidisciplinary panel recommend development of a curriculum on pediatric medication safety that could be offered to all caregivers of children in emergency settings. A standard curriculum may include content such as common medication errors in children, systems-improvement tools to avoid or abate errors, and the effects of developmental differences in pediatric patients. Demonstrating competency on the basis of this curriculum is 1 means by which institutions may reduce risks of medication errors.

The dispensing and administration phases serve as final opportunities to optimize medication safety. Strategies to reduce errors include standardizing the concentrations available for a given drug, having readily available and up-to-date medication reference materials, using premixed intravenous preparations when possible, having automated dispensing cabinets with appropriate pediatric dosage formulations, using barcoded medication administration,62  having pharmacists and ED care providers work effectively as a team, and having policies to guide medication use.63,64  Although yet to be studied in the ED environment, smart infusion pumps have shown promise in other arenas in reducing administration errors for infusions.65 

Nurses are held accountable by each state’s nurse practice act for the appropriateness of all medications given. Nursing schools teach the 5 rights of medication administration: the right patient, the right medication, the right dose, the right time, and the right route.66  Elliott and Liu67  expand the 5 rights to include right documentation, right action, right form, and right response to further improve medication safety. Simulated medication administration addresses opportunities beyond those captured within these rights and may have implications within the ED.68  Additionally, given the association of medication preparation interruptions and administration errors,69  the use of a distraction-free medication safety zone has been shown to enhance medication safety.70,71  Implementation of an independent 2-provider check process for high-alert medications, as suggested by The Joint Commission, also reduces administration errors.72  Both the Institute for Safe Medication Practices and The Joint Commission provide excellent guidance on these topics.73 

Recognizing and addressing language barriers and health literacy variability in the ED can affect medication safety in the home. Nonstandardized delivery devices continue to be used in the home, and dosing error rates of greater than 40% are reported.74  Advanced counseling and instrument provision in the ED are proven to decrease dosing errors at home.75  Pictograms provided to aide in medication measurement have also been shown to decrease errors and may be considered as part of discharge instructions.76  The AAP supports policy on the use of milliliter-only dosing for liquid medications used in the home and suggests that standardized delivery devices be distributed from the ED for use with these medications.77  As the body of literature regarding health literacy evolves, further addressing these issues in real time may influence out- of-hospital care.

Pediatric medication safety requires a multidisciplinary approach across the continuum of emergency care, starting in the prehospital setting, during emergency care, and beyond. Key areas for medication safety specific to pediatric care in the ED include the creation of standardized medication dosing guidelines, better integration and use of information technology to support patient safety, and increased education standards across health care disciplines. The following is a list of specific recommendations that can lead to improved pediatric medication safety in the emergency care setting.

  1. Create a standard formulary for pediatric high-risk and commonly used medications;

  2. standardize concentrations of high-risk medications;

  3. reduce the number of available concentrations to the smallest possible number;

  4. provide recommended precalculated doses;

  5. measure and record weight in kilograms only;

  6. use length-based dosing tools when a scale is unavailable or use is not feasible;

  7. implement and support the availability of pharmacists in the ED;

  8. use standardized order sets with embedded best practice prescribing and dosing range maximums;

  9. promote the development of distraction-free medication safety zones for medication preparation;

  10. implement process screening, such as a 2-provider independent check for high-alert medications;

  11. implement and use CPOE and CDS with pediatric-specific kilogram-only dosing rules, including upper dosing limits within ED information systems;

  12. encourage community providers of children with medical complexity to maintain a current medication list and an emergency information form to be available for emergency care;

  13. create and integrate a dedicated pediatric medication safety curriculum into training programs for nurses, physicians, respiratory therapists, nurse practitioners, physician assistants, prehospital providers, and pharmacists;

  14. develop tools for competency assessment;

  15. dispense standardized delivery devices for home administration of liquid medications;

  16. dispense milliliter-only dosing for liquid medications used in the home;

  17. employ advanced counseling such as teach-back when sharing medication instructions for home use; and

  18. use pictogram-based dosing instruction sheets for use of home medications.

Lee Benjamin, MD, FAAP, FACEP

Karen Frush, MD, FAAP

Kathy Shaw, MD, MSCE, FAAP

Joan E. Shook, MD, MBA, FAAP

Sally K. Snow, BSN, RN, CPEN, FAEN

Joseph Wright, MD, MPH, FAAP, Chairperson

Terry Adirim, MD, MPH, FAAP

Michael S.D. Agus, MD, FAAP

James Callahan, MD, FAAP

Toni Gross, MD, MPH, FAAP

Natalie Lane, MD, FAAP

Lois Lee, MD, MPH, FAAP

Suzan Mazor, MD, FAAP

Prashant Mahajan, MD, MPH, MBA, FAAP

Nathan Timm, MD

Andrew Eisenberg, MD – American Academy of Family Physicians

Cynthia Wright Johnson, MSN, RN – National Association of State Emergency Medical Service Officials

Cynthiana Lightfoot, BFA, NRP – AAP Family Partnerships Network

Charles Macias, MD, MPH, FAAP – Emergency Medical Service for Children Innovation and Improvement Center

Brian Moore, MD, MPH, FAAP – National Association of Emergency Medical Service Physicians

Diane Pilkey, RN, MPH – Maternal and Child Health Bureau

Katherine Remick, MD, FAAP – National Association of Emergency Medical Technicians

Mohsen Saidinejad, MD, MBA, FAAP, FACEP – ACEP

Sally Snow, RN, BSN, CPEN, FAEN – ENA

David Tuggle, MD, FAAP – American College of Surgeons

Alice Ackerman, MD, MBA

Thomas Chun, MD, MPH, FAAP

Gregory Conners, MD, MPH, MBA, FAAP

Edward Conway, Jr, MD, MS, FAAP

Nanette Dudley, MD, FAAP

Joel Fein, MD

Susan Fuchs, MD, FAAP

Marc Gorelick, MD, MSCE

Natalie Lane, MD, FAAP

Charles Macias, MD, MPH, FAAP

Brian Moore, MD, FAAP

Steven Selbst, MD

Kathy Shaw, MD, MSCE, Chair (2008–2012)

Joan Shook, MD, MBA, FAAP, Chair (2012–2016)

Joseph Wright, MD, MPH, FAAP

Sue Tellez

Tamar Margarik Haro

Madeline Joseph, MD, FACEP, Chair

Kiyetta Alade, MD

Christopher Amato, MD, FACEP

Jahn T. Avarello, MD, FACEP

Steven Baldwin, MD

Isabel A. Barata, MD, FACEP, FAAP

Lee S. Benjamin, MD, FACEP

Kathleen Berg, MD

Kathleen Brown, MD, FACEP

Jeffrey Bullard-Berent, MD, FACEP

Ann Marie Dietrich, MD, FACEP

Phillip Friesen, DO

Michael Gerardi, MD, FACEP, FAAP

Alan Heins, MD, FACEP

Doug K. Holtzman, MD, FACEP

Jeffrey Homme, MD, FACEP

Timothy Horeczko, MD, MSCR

Paul Ishimine, MD, FACEP

Samuel Lam, MD, RDMS

Katharine Long

Kurtis Mayz, JD, MD, MBA

Sanjay Mehta, MD, Med, FACEP

Larry Mellick, MD

Aderonke Ojo, MD, MBBS

Audrey Z. Paul, MD, PhD

Denis R. Pauze, MD, FACEP

Nadia M. Pearson, DO

Debra Perina, MD, FACEP

Emory Petrack, MD

David Rayburn, MD, MPH

Emily Rose, MD

W. Scott Russell, MD, FACEP

Timothy Ruttan, MD, FACEP

Mohsen Saidinejad, MD, MBA, FACEP

Brian Sanders, MD

Joelle Simpson, MD, MPH

Patrick Solari, MD

Michael Stoner, MD

Jonathan H. Valente, MD, FACEP

Jessica Wall, MD

Dina Wallin, MD

Muhammad Waseem, MD, MS, FACEP

Paula J. Whiteman, MD, FACEP

Dale Woolridge, MD, PhD, FACEP

Joseph Arms, MD

Richard M. Cantor, MD, FACEP

Ariel Cohen, MD

Carrie DeMoor, MD

James M. Dy, MD

Paul J. Eakin, MD Sean Fox, MD

Marianne Gausche-Hill, MD, FACEP, FAAP

Timothy Givens, MD

Charles J. Graham, MD, FACEP

Robert J. Hoffman, MD, FACEP

Mark Hostetler, MD, FACEP

Hasmig Jinivizian, MD

David Markenson, MD, MBA, FACEP

Joshua Rocker, MD, FACEP

Brett Rosen, MD

Gerald R. Schwartz, MD, FACEP

Harold A. Sloas, DO

Annalise Sorrentino, MD, FACEP

Orel Swenson, MD

Michael Witt, MD, MPH, FACEP

Loren Rives, MNA

Dan Sullivan

Stephanie Wauson

Tiffany Young, BSN, RN, CPNP, 2016 Chair

Joyce Foresman-Capuzzi, MSN, RN, CNS, 2017 Chair

Rose Johnson, RN

Heather Martin, DNP, MS RN, PNP-BC

Justin Milici, MSN, RN

Cam Brandt, MS, RN

Nicholas Nelson, MS RN, EMT-P

Maureen Curtis-Cooper, BSN, RN, 2016 Board Liaison

Kathleen Carlson, MSN, RN, 2017 Board Liaison

Marlene Bokholdt, MSN, RN

Mohsen Saidinejad, MD, MS, MBA, FAAP, FACEP

Mark X. Cicero, MD, FAAP

All authors contributed to the writing and organization of the policy statement and reviewed and support the final submission.

This document is copyrighted and is property of the American Academy of Pediatrics and American College of Emergency Physicians and their Boards of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association have neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Jointly published in the Annals of Emergency Medicine.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

AAP

American Academy of Pediatrics

ACEP

American College of Emergency Physicians

ADE

adverse drug event

CDS

clinical decision support

CPOE

computerized physician order entry

ED

emergency department

ENA

Emergency Nurses Association

1
Institute of Medicine, Committee on Quality of Health Care in America
. In:
Kohn
LT
,
Corrigan
JM
,
Donaldson
MS
, eds.
To Err is Human: Building a Safer Health System
.
Washington, DC
:
National Academies Press
;
1999
2
Leape
LL
,
Brennan
TA
,
Laird
N
, et al
.
The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II
.
N Engl J Med
.
1991
;
324
(
6
):
377
384
3
Kaushal
R
,
Bates
DW
,
Landrigan
C
, et al
.
Medication errors and adverse drug events in pediatric inpatients
.
JAMA
.
2001
;
285
(
16
):
2114
2120
4
Woo
Y
,
Kim
HE
,
Chung
S
,
Park
BJ
.
Pediatric medication error reports in Korea adverse event reporting system database, 1989–2012: comparing with adult reports
.
J Korean Med Sci
.
2015
;
30
(
4
):
371
377
5
Institute of Medicine, Committee of the Future of Emergency Care in the US Health System.
Emergency Care for Children: Growing Pains
.
Washington, DC
:
National Academies Press
;
2006
6
Shaw
KN
,
Lillis
KA
,
Ruddy
RM
, et al
;
Pediatric Emergency Care Applied Research Network
.
Reported medication events in a paediatric emergency research network: sharing to improve patient safety
.
Emerg Med J
.
2013
;
30
(
10
):
815
819
7
Rinke
ML
,
Moon
M
,
Clark
JS
,
Mudd
S
,
Miller
MR
.
Prescribing errors in a pediatric emergency department
.
Pediatr Emerg Care
.
2008
;
24
(
1
):
1
8
8
Berg
LM
,
Källberg
AS
,
Göransson
KE
,
Östergren
J
,
Florin
J
,
Ehrenberg
A
.
Interruptions in emergency department work: an observational and interview study
.
BMJ Qual Saf
.
2013
;
22
(
8
):
656
663
9
Thomasset
KB
,
Faris
R
.
Survey of pharmacy services provision in the emergency department
.
Am J Health Syst Pharm
.
2003
;
60
(
15
):
1561
1564
10
Cesarz
JL
,
Steffenhagen
AL
,
Svenson
J
,
Hamedani
AG
.
Emergency department discharge prescription interventions by emergency medicine pharmacists
.
Ann Emerg Med
.
2013
;
61
(
2
):
209
14.e1
11
Patanwala
AE
,
Warholak
TL
,
Sanders
AB
,
Erstad
BL
.
A prospective observational study of medication errors in a tertiary care emergency department
.
Ann Emerg Med
.
2010
;
55
(
6
):
522
526
12.
Wyatt
KD
,
Benning
TJ
,
Morgenthaler
TI
,
Arteaga
GM.
Development of a taxonomy for medication-related patient safety events related to health information technology in pediatrics
.
Appl Clin Inform.
2020
;
11
(
5
):
714
724
13
Gausche-Hill
M
,
Schmitz
C
,
Lewis
RJ
.
Pediatric preparedness of US emergency departments: a 2003 survey
.
Pediatrics
.
2007
;
120
(
6
):
1229
1237
14
Hoyle
JD
,
Davis
AT
,
Putman
KK
,
Trytko
JA
,
Fales
WD
.
Medication dosing errors in pediatric patients treated by emergency medical services
.
Prehosp Emerg Care
.
2012
;
16
(
1
):
59
66
15
Kozer
E
,
Scolnik
D
,
Macpherson
A
, et al
.
Variables associated with medication errors in pediatric emergency medicine
.
Pediatrics
.
2002
;
110
(
4
):
737
742
16
Sard
BE
,
Walsh
KE
,
Doros
G
,
Hannon
M
,
Moschetti
W
,
Bauchner
H
.
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department
.
Pediatrics
.
2008
;
122
(
4
):
782
787
17
Marcin
JP
,
Dharmar
M
,
Cho
M
, et al
.
Medication errors among acutely ill and injured children treated in rural emergency departments
.
Ann Emerg Med
.
2007
;
50
(
4
):
361
367
,
367.e1–367.e2
18.
Kassem
AB
,
Saeed
H
,
El Bassiouny
NA
,
Kamal
M.
Assessment and analysis of outpatient medication errors related to pediatric prescriptions
.
Saudi Pharm J.
2021
;
29
(
10
):
1090
1095
19
Lesar
TS
.
Tenfold medication dose prescribing errors
.
Ann Pharmacother
.
2002
;
36
(
12
):
1833
1839
20
Doherty
C
,
Mc Donnell
C
.
Tenfold medication errors: 5 years’ experience at a university-affiliated pediatric hospital
.
Pediatrics
.
2012
;
129
(
5
):
916
924
21
Harskamp-van Ginkel
MW
,
Hill
KD
,
Becker
KC
, et al
;
Best Pharmaceuticals for Children Act–Pediatric Trials Network Administrative Core Committee
.
Drug dosing and pharmacokinetics in children with obesity: a systematic review [published correction appears in JAMA Pediatr. 2015;169(12):1179]
.
JAMA Pediatr
.
2015
;
169
(
7
):
678
685
22
Miller
JL
,
Johnson
PN
,
Harrison
DL
,
Hagemann
TM
.
Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children
.
Ann Pharmacother
.
2010
;
44
(
1
):
35
42
23
Young
KD
,
Korotzer
NC
.
Weight estimation methods in children: a systematic review
.
Ann Emerg Med
.
2016
;
68
(
4
):
441
451.e10
24
Zorc
JJ
,
Hoffman
JM
,
Harper
MB
.
IT in the ED: a new section of Pediatric Emergency Care
.
Pediatr Emerg Care
.
2012
;
28
(
12
):
1399
1401
25.
Whalen
K
,
Lynch
E
,
Moawad
I
,
John
T
,
Lozowski
D
,
Cummings
BM.
Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system
.
J Am Med Inform Assoc.
2018
;
25
(
7
):
848
854
26
van der Sijs
H
,
Aarts
J
,
Vulto
A
,
Berg
M
.
Overriding of drug safety alerts in computerized physician order entry
.
J Am Med Inform Assoc
.
2006
;
13
(
2
):
138
147
27
Her
QL
,
Seger
DL
,
Amato
MG
, et al
.
Development of an algorithm to assess appropriateness of overriding alerts for nonformulary medications in a computerized prescriber-order-entry system
.
Am J Health Syst Pharm
.
2016
;
73
(
1
):
e34
e45
28
Radley
DC
,
Wasserman
MR
,
Olsho
LE
,
Shoemaker
SJ
,
Spranca
MD
,
Bradshaw
B
.
Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems
.
J Am Med Inform Assoc
.
2013
;
20
(
3
):
470
476
29.
Ratwani
RM
,
Savage
E
,
Will
A
, et al
.
Identifying electronic health record usability and safety challenges in pediatric settings
.
Health Aff (Millwood).
2018
;
37
(
11
):
1752
1759
30
Larose
G
,
Bailey
B
,
Lebel
D
.
Quality of orders for medication in the resuscitation room of a pediatric emergency department
.
Pediatr Emerg Care
.
2008
;
24
(
9
):
609
614
31
Broussard
M
,
Bass
PF III
,
Arnold
CL
,
McLarty
JW
,
Bocchini
JA
Jr
.
Preprinted order sets as a safety intervention in pediatric sedation
.
J Pediatr
.
2009
;
154
(
6
):
865
868
32
Burmester
MK
,
Dionne
R
,
Thiagarajan
RR
,
Laussen
PC
.
Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit
.
Intensive Care Med
.
2008
;
34
(
6
):
1083
1090
33
Institute for Safe Medication Practices. ISMP medication safety alert.
Progress with preventing name confusion errors
.
2007
. Available at: https://www.ismp.org/newsletters/acutecare/articles/20070809.asp. Accessed November 16, 2016
34.
Thabet
Y
,
Klingmann
V
,
Breitkreutz
J.
Drug Formulations: Standards and Novel Strategies for Drug Administration in Pediatrics
.
J Clin Pharmacol.
2018
;
58
(Suppl
10
):
S26
S35
35.
Green
FG
,
Park
K
,
Burckart
GJ.
Methods used for pediatric dose selection in drug development programs submitted to the US FDA 2012-2020
.
J Clin Pharmacol.
2021
;
61
(Suppl
1
):
S28
S35
36
Murray
KL
,
Wright
D
,
Laxton
B
,
Miller
KM
,
Meyers
J
,
Englebright
J
.
Implementation of standardized pediatric i.v. medication concentrations
.
Am J Health Syst Pharm
.
2014
;
71
(
17
):
1500
1508
37
American Society of Health-System Pharmacists
.
ASHP awarded FDA contract to improve safety of intravenous and oral liquid medications: standardization contract is part of FDA’s Safe Use Initiative [press release]
. Available at: https://www.ashp.org/news/2017/02/09/16/44/standardize-4-safety-initiative-releases-final-iv-recommendations-for- medication-safety. Accessed November 16,
2016
38
Shaw
KN
,
Ruddy
RM
,
Olsen
CS
, et al
;
Pediatric Emergency Care Applied Research Network
.
Pediatric patient safety in emergency departments: unit characteristics and staff perceptions
.
Pediatrics
.
2009
;
124
(
2
):
485
493
39
Thomas
MC
,
Acquisto
NM
,
Shirk
MB
,
Patanwala
AE
.
A national survey of emergency pharmacy practice in the United States
.
Am J Health Syst Pharm
.
2016
;
73
(
6
):
386
394
40
American College of Emergency Physicians
.
Clinical pharmacist services in the emergency department
.
2015
. Available at: https://www.acep.org/clinical–practice-management/clinical-pharmacist-services-in-the-emergency-department/. Accessed November 16, 2016
41
Johnston
R
,
Saulnier
L
,
Gould
O
.
Best possible medication history in the emergency department: comparing pharmacy technicians and pharmacists
.
Can J Hosp Pharm
.
2010
;
63
(
5
):
359
365
42
Emergency Nurses Association
.
Position statement: role of the emergency nurse in medication reconciliation
.
Des Plaines, IL
:
Emergency Nurses Association
;
2015
. Available at: https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/roleofednurseinme_dicationreconcilation.pdf?sfvrsn=8c413f53_8. Accessed November 29, 2016
43
American Academy of Pediatrics; Committee on Pediatric Emergency Medicine and Council on Clinical Information Technology; American College of Emergency Physicians; Pediatric Emergency Medicine Committee
.
Policy statement— emergency information forms and emergency preparedness for children with special health care needs
.
Pediatrics
.
2010
;
125
(
4
):
829
837
44
Stone
BL
,
Boehme
S
,
Mundorff
MB
,
Maloney
CG
,
Srivastava
R
.
Hospital admission medication reconciliation in medically complex children: an observational study
.
Arch Dis Child
.
2010
;
95
(
4
):
250
255
45
Provine
AD
,
Simmons
EM
,
Bhagat
PH
.
Establishment and evaluation of pharmacist-managed admission medication history and reconciliation process for pediatric patients
.
J Pediatr Pharmacol Ther
.
2014
;
19
(
2
):
98
102
46
Gardner
B
,
Graner
K
.
Pharmacists’ medication reconciliation-related clinical interventions in a children’s hospital
.
Jt Comm J Qual Patient Saf
.
2009
;
35
(
5
):
278
282
47
American Society of Health-System Pharmacists
.
ASHP guidelines on emergency medicine pharmacist services
. Available at: https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/emergency-medicine- pharmacist-services.ashx?la=en&hash=6503B2C3B0F5382A00FD3FCC9190E803D6C4BA2F. Accessed November 16,
2016
48
Scott
DM
,
Friesner
DL
,
Rathke
AM
,
Doherty-Johnsen
S
.
Medication error reporting in rural critical access hospitals in the North Dakota Telepharmacy Project
.
Am J Health Syst Pharm
.
2014
;
71
(
1
):
58
67
49
Cole
SL
,
Grubbs
JH
,
Din
C
,
Nesbitt
TS
.
Rural inpatient telepharmacy consultation demonstration for after- hours medication review
.
Telemed J E Health
.
2012
;
18
(
7
):
530
537
50
Patanwala
AE
,
Sanders
AB
,
Thomas
MC
, et al
.
A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department
.
Ann Emerg Med
.
2012
;
59
(
5
):
369
373
51
Aldridge
VE
,
Park
HK
,
Bounthavong
M
,
Morreale
AP
.
Implementing a comprehensive, 24-hour emergency department pharmacy program
.
Am J Health Syst Pharm
.
2009
;
66
(
21
):
1943
1947
52
Lada
P
,
Delgado
G
Jr
.
Documentation of pharmacists’ interventions in an emergency department and associated cost avoidance
.
Am J Health Syst Pharm
.
2007
;
64
(
1
):
63
68
53
Warholak
TL
,
Queiruga
C
,
Roush
R
,
Phan
H
.
Medication error identification rates by pharmacy, medical, and nursing students
.
Am J Pharm Educ
.
2011
;
75
(
2
):
24
54.
Cicero
MX
,
Adelgais
K
,
Hoyle
JD
, et al
.
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
.
Prehosp Emerg Care.
2021
;
25
(
2
):
294
306
55.
Kaufmann
J
,
Uhl
S
,
Singer
E
, et al
.
Improving pediatric drug safety in prehospital emergency care-10 years on
.
J Patient Saf.
2021
;
17
(
8
):
e1241
e1246
56.
Hoyle
JD
,
Ekblad
G
,
Woodwyk
A
,
Brandt
R
,
Fales
B
,
Lammers
RL.
Methods used to obtain pediatric patient weights, their accuracy and associated drug dosing errors in 142 simulated prehospital pediatric patient encounters
.
Prehosp Emerg Care.
2022
;
26
(
4
):
511
518
57
Accreditation Council for Graduate Medical Education.
ACGME program requirements for graduate medical education in pediatrics
. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/320_ pediatrics_2017-07-01.pdf. Accessed January 10,
2018
58
Accreditation Council for Graduate Medical Education.
ACGME program requirements for graduate medical education in emergency medicine
. Available at: https://www.acgme.org/ Portals/0/PFAssets/ProgramRequirements/ 110_emergency_medicine_2017-07-01.pdf. Accessed January 10,
2018
59
Accreditation Council for Graduate Medical Education
.
ACGME program requirements for graduate medical education in pediatric emergency medicine
. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/114_emergency_ med_peds_2017-07-01.pdf?ver=2017-05-18-091501-330. Accessed January 10,
2018
60
Accreditation Council for Pharmacy Education.
ACPE accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree
. Available at: https://acpe-accredit.org/pdf/FinalS2007Guidelines2.0.pdf. Accessed November 16,
2016
61
Emergency Medical Services for Children/National Resource Center
.
Pediatric patient safety toolbox
. Available at: https://emscimprovement.center/resources/toolboxes/pediatric- patient-safety-toolbox/. Accessed November 16,
2016
62
Poon
EG
,
Cina
JL
,
Churchill
W
, et al
.
Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy
.
Ann Intern Med
.
2006
;
145
(
6
):
426
434
63
Rinke
ML
,
Bundy
DG
,
Velasquez
CA
, et al
.
Interventions to reduce pediatric medication errors: a systematic review
.
Pediatrics
.
2014
;
134
(
2
):
338
360
64
ED-based pharmacists make a big dent in medication errors
.
ED Manag
.
2014
;
26
(
8
):
91
94
65
Manrique-Rodríguez
S
,
Sánchez- Galindo
AC
,
López-Herce
J
, et al
.
Impact of implementing smart infusion pumps in a pediatric intensive care unit
.
Am J Health Syst Pharm
.
2013
;
70
(
21
):
1897
1906
66
Nugent
P
,
Vitale
BA
. In:
Nugent
PM
,
Vitale
BA
, eds.
Fundamentals of Nursing: Content Review Plus Practice Questions
.
Philadelphia
,
PA: F.A. Davis Company
;
2013
:
361
362
67
Elliott
M
,
Liu
Y
.
The nine rights of medication administration: an overview
.
Br J Nurs
.
2010
;
19
(
5
):
300
305
68
Pauly-
O’Neill
S. Beyond the five rights: improving patient safety in pediatric medication administration through simulation
.
Clin Simul Nurs
.
2009
;
5
(
5
):
e181
e186
69
Westbrook
JI
,
Woods
A
,
Rob
MI
,
Dunsmuir
WT
,
Day
RO
.
Association of interruptions with an increased risk and severity of medication administration errors
.
Arch Intern Med
.
2010
;
170
(
8
):
683
690
70
Anthony
K
,
Wiencek
C
,
Bauer
C
,
Daly
B
,
Anthony
MK
.
No interruptions please: impact of a No Interruption Zone on medication safety in intensive care units
.
Crit Care Nurse
.
2010
;
30
(
3
):
21
29
71
United States Pharmacopeial Convention
.
Physical environments that promote safe medication use. Revision bulletin
.
2010
. Available at: http://www.uspnf.com/sites/default/files/usp_pdf/EN/USPNF/c1066.pdf. Accessed November 16, 2016
72
The Joint Commission
.
Preventing pediatric medication errors
.
Sentinel Event Alert
.
2008
;(
39
):
1
4
73
American Hospital Association, Health Research and Educational Trust, Institute for Safe Medication Practices
.
Pathways for medication safety: looking collectively at risk
. Available at: www.ismp.org/tools/pathwaysection2.pdf. Accessed November 16,
2016
74
Yin
HS
,
Dreyer
BP
,
Ugboaja
DC
, et al
.
Unit of measurement used and parent medication dosing errors
.
Pediatrics
.
2014
;
134
(
2
). Available at: www. pediatrics.org/cgi/content/full/134/2/e354
75.
Naureckas Li
C
,
Camargo
CA
,
Faridi
M
, et al
.
Medication education for dosing safety: a randomized controlled trial
.
Ann Emerg Med.
2020
;
76
(
5
):
637
645
76
Chan
HK
,
Hassali
MA
,
Lim
CJ
,
Saleem
F
,
Tan
WL
.
Using pictograms to assist caregivers in liquid medication administration: a systematic review
.
J Clin Pharm Ther
.
2015
;
40
(
3
):
266
272
77
American Academy of Pediatrics, Committee on Drugs
.
Metric units and the preferred dosing of orally administered liquid medications
.
Pediatrics
.
2015
;
135
(
4
):
784
787

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.