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Interventions to Reduce Pediatric Prescribing Errors in Professional Healthcare Settings: A Systematic Review of the Last Decade

Abstract

Introduction

Pediatric medication therapy is prone to errors due to the need for pharmacokinetic and pharmacodynamic individualization and the diverse settings in which pediatric patients are treated. Prescribing errors have been reported as the most common medication error.

Objectives

The aim of this review was to systematically identify interventions to reduce prescribing errors and corresponding patient harm in pediatric healthcare settings and to evaluate their impact.

Methods

Four databases were systematically screened (time range November 2011 to December 2019), and experimental studies were included. Interventions to reduce prescribing errors were extracted and classified according to a ‘hierarchy of controls’ model.

Results

Forty-five studies were included, and 70 individual interventions were identified. A bundle of interventions was more likely to reduce prescribing errors than a single intervention. Interventions classified as ‘substitution or engineering controls’ were more likely to reduce errors in comparison with ‘administrative controls’, as is expected from the hierarchy of controls model. Fourteen interventions were classified as substitution or engineering controls, including computerized physician order entry (CPOE) and clinical decision support (CDS) systems. Administrative controls, including education, expert consultations, and guidelines, were more commonly identified than higher level controls, although they may be less likely to reduce errors. Of the administrative controls, expert consultations were most likely to reduce errors.

Conclusions

Interventions to reduce pediatric prescribing errors are more likely to be successful when implemented as part of a bundle of interventions. Interventions including CPOE and CDS that substitute risks or provide engineering controls should be prioritized and implemented with appropriate administrative controls including expert consultation.

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Correspondence to Joachim A. Koeck.

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JK, NY, UK, TO, DB, AE: None to declare.

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The protocol was registered in PROSPERO (reg. no. CRD42016047127) and with the local ethics commission (EK 158/17).

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JK was responsible for search, data extraction/analysis, and drafted the first manuscript. NY assisted in the data analysis. UK, TO, and DB contributed to interpretation of data. AE developed the concept, supervised, and assisted with data extraction/analysis. JK, NY, UK, TO, DB, and AE revisited the manuscript critically for important intellectual content. They approved the final manuscript as submitted and take full responsibility for the manuscript. All authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Koeck, J.A., Young, N.J., Kontny, U. et al. Interventions to Reduce Pediatric Prescribing Errors in Professional Healthcare Settings: A Systematic Review of the Last Decade. Pediatr Drugs 23, 223–240 (2021). https://doi.org/10.1007/s40272-021-00450-6

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