Skip to main content

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



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.


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.


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.


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.


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.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6


  1. 1.

    Reason J. Human error: models and management. BMJ (clinical research ed). 2000;320(7237):768–70.

    CAS  PubMed Central  Google Scholar 

  2. 2.

    Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: Committee on Quality of Health Care in America, Institute of Medicine; 2000.

    Google Scholar 

  3. 3.

    Medication Without Harm. World Health Organization. 2017.;jsessionid=D8A06BFA891A812F8CFCDEFB7A30AAF9?sequence=1. Accessed 10 Dec 2020.

  4. 4.

    Promoting safety of medicines for children. World Health Organization. 2007. Accessed 02 Nov 2020.

  5. 5.

    Avidan A, Levin PD, Weissman C, Gozal Y. Anesthesiologists’ ability in calculating weight-based concentrations for pediatric drug infusions: an observational study. J Clin Anesth. 2014;26(4):276–80.

    CAS  PubMed  Google Scholar 

  6. 6.

    Hodkinson A, Tyler N, Ashcroft DM, Keers RN, Khan K, Phipps D, et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med. 2020 6;18(1):313.

  7. 7.

    Rinke ML, Bundy DG, Velasquez CA, Rao S, Zerhouni Y, Lobner K, et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics. 2014;134(2):338–60.

    PubMed  Google Scholar 

  8. 8.

    Maaskant JM, Vermeulen H, Apampa B, Fernando B, Ghaleb MA, Neubert A, et al. Interventions for reducing medication errors in children in hospital. Cochrane Database Syst Rev. 2015;3:Cd006208.

  9. 9.

    Manias E, Kinney S, Cranswick N, Williams A, Borrott N. Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother. 2014;48(10):1313–31.

    PubMed  Google Scholar 

  10. 10.

    Pintor-Marmol A, Baena MI, Fajardo PC, Sabater-Hernandez D, Saez-Benito L, Garcia-Cardenas MV, et al. Terms used in patient safety related to medication: a literature review. Pharmacoepidemiol Drug Saf. 2012;21(8):799–809.

    PubMed  Google Scholar 

  11. 11.

    Falconer N, Barras M, Martin J, Cottrell N. Defining and classifying terminology for medication harm: a call for consensus. Eur J Clin Pharmacol. 2019;75(2):137–45.

    CAS  PubMed  Google Scholar 

  12. 12.

    Roumeliotis N, Sniderman J, Adams-Webber T, Addo N, Anand V, Rochon P, et al. Effect of electronic prescribing strategies on medication error and harm in hospital: a systematic review and meta-analysis. J Gen Intern Med. 2019;34(10):2210–23.

    PubMed  PubMed Central  Google Scholar 

  13. 13.

    Nguyen MR, Mosel C, Grzeskowiak LE. Interventions to reduce medication errors in neonatal care: a systematic review. Ther Adv Drug Saf. 2018;9(2):123–55.

    PubMed  Google Scholar 

  14. 14.

    Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care. 2007;16(2):116–26.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009 21;6(7):e1000100.

  16. 16.

    Becker SC. Contemporary view of medication-related harm. A new paradigm. National Coordinating Council for medication error reporting and prevention. 2015. Accessed 22 Dec 2020.

  17. 17.

    NCC MERP index for categorizing medication errors. National coordinating council for medication error reporting and prevention. 2001. Accessed 20 Jul 2016.

  18. 18.

    Dean B, Barber N, Schachter M. What is a prescribing error? Quality Health Care QHC. 2000;9(4):232–7.

    CAS  PubMed  Google Scholar 

  19. 19.

    What study designs should be included in an EPOC review and what should they be called? Cochrane Effective Practice and Organisation of Care. 2017. Accessed 22 Dec 2020.

  20. 20.

    Aitken M, Gorokhovich L. Advancing the responsible use of medicines: applying levers for change. Available at SSRN 2222541. 2012.

  21. 21.

    Parand A, Garfield S, Vincent C, Franklin BD. Carers’ medication administration errors in the domiciliary setting: a systematic review. PLoS ONE. 2016;11(12):e0167204.

    PubMed  PubMed Central  Google Scholar 

  22. 22.

    Krzyzaniak N, Bajorek B. Medication safety in neonatal care: a review of medication errors among neonates. Ther Adv Drug Saf. 2016;7(3):102–19.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Berdot S, Roudot M, Schramm C, Katsahian S, Durieux P, Sabatier B. Interventions to reduce nurses’ medication administration errors in inpatient settings: a systematic review and meta-analysis. Int J Nurs Stud. 2016;53:342–50.

    PubMed  Google Scholar 

  24. 24.

    Bannan DF, Tully MP. Bundle interventions used to reduce prescribing and administration errors in hospitalized children: a systematic review. J Clin Pharm Ther. 2016;41(3):246–55.

    CAS  PubMed  Google Scholar 

  25. 25.

    Wimmer S, Neubert A, Rascher W. The safety of drug therapy in children. Dtsch Arztebl. 2015;112(46):781–7.

    Google Scholar 

  26. 26.

    Santesteban E, Arenas S, Campino A. Medication errors in neonatal care: a systematic review of types of errors and effectiveness of preventive strategies. J Neonatal Nurs. 2015;21(5):200–8.

    Google Scholar 

  27. 27.

    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):266–72.

    CAS  PubMed  Google Scholar 

  28. 28.

    Bower R, Jackson C, Manning JC. Interruptions and medication administration in critical care. Nurs Crit Care. 2015;20(4):183–95.

    PubMed  Google Scholar 

  29. 29.

    Alomari A, Wilson V, Davidson PM, Lewis J. Families, nurses and organisations contributing factors to medication administration error in paediatrics: a literature review. Int Pract Dev J. 2015;5(1):1–14.

    Google Scholar 

  30. 30.

    Nuckols TK, Smith-Spangler C, Morton SC, Asch SM, Patel VM, Anderson LJ, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Syst Rev. 20143:56.

  31. 31.

    Neuspiel DR, Taylor MM. Reducing the risk of harm from medication errors in children. Health Serv Insights. 2013;6:47–59.

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    Huynh C, Wong IC, Tomlin S, Terry D, Sinclair A, Wilson K, et al. Medication discrepancies at transitions in pediatrics: a review of the literature. Paediatr Drugs. 2013;15(3):203–15.

    PubMed  Google Scholar 

  33. 33.

    Garfield S, Reynolds M, Dermont L, Franklin BD. Measuring the severity of prescribing errors: a systematic review. Drug Saf. 2013;36(12):1151–7.

    PubMed  PubMed Central  Google Scholar 

  34. 34.

    Mehndiratta S. Strategies to reduce medication errors in pediatric ambulatory settings. J Postgrad Med. 2012;58(1):47–53.

    CAS  PubMed  Google Scholar 

  35. 35.

    Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review of the literature. J Pediatr Nurs. 2012;27(4):416–20.

    PubMed  Google Scholar 

  36. 36.

    Kaufmann J, Laschat M, Wappler F. Medication errors in pediatric emergencies: a systematic analysis. Deutsches Arzteblatt Int. 2012;109(38):609–16.

    Google Scholar 

  37. 37.

    Alsulami Z, Conroy S, Choonara I. Double checking the administration of medicines: what is the evidence? A systematic review. Arch Dis Child. 2012;97(9):833–7.

    PubMed  Google Scholar 

  38. 38.

    Wilson S, Bremner A, Hauck Y, Finn J. The effect of nurse staffing on clinical outcomes of children in hospital: a systematic review. Int J Evid Based Healthc. 2011;9(2):97–121.

    PubMed  Google Scholar 

  39. 39.

    Davis T. Paediatric prescribing errors. Arch Dis Child. 2011;96(5):489–91.

    PubMed  Google Scholar 

  40. 40.

    Alghamdi AA, Keers RN, Sutherland A, Ashcroft DM. Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review. Drug Saf. 2019;42(12):1423–36.

    CAS  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Alsaidan J, Portlock J, Aljadhey HS, Shebl NA, Franklin BD. Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries. Saudi Pharmaceut J (SPJ). 2018;26(7):977–1011.

    Google Scholar 

  42. 42.

    Drovandi A, Robertson K, Tucker M, Robinson N, Perks S, Kairuz T. A systematic review of clinical pharmacist interventions in paediatric hospital patients. Eur J Pediatr. 2018;177(8):1139–48.

    PubMed  Google Scholar 

  43. 43.

    Feinstein MM, Pannunzio AE, Castro P. Frequency of medication error in pediatric anesthesia: a systematic review and meta-analytic estimate. Paediatr Anaesth. 2018;28(12):1071–7.

    PubMed  Google Scholar 

  44. 44.

    Gates PJ, Meyerson SA, Baysari MT, Lehmann CU, Westbrook JI. Preventable adverse drug events among inpatients: a systematic review. Pediatrics. 2018;142(3).

  45. 45.

    Gates PJ, Meyerson SA, Baysari MT, Westbrook JI. The Prevalence of dose errors among paediatric patients in hospital wards with and without health information technology: a systematic review and meta-analysis. Drug Saf. 2019;42(1):13–25.

    CAS  PubMed  Google Scholar 

  46. 46.

    Gates PJ, Baysari MT, Gazarian M, Raban MZ, Meyerson S, Westbrook JI. Prevalence of medication errors among paediatric inpatients: systematic review and meta-analysis. Drug Saf. 2019;42(11):1329–42.

    CAS  PubMed  Google Scholar 

  47. 47.

    Kahn S, Abramson EL. What is new in paediatric medication safety? Arch Dis Child. 2019;104(6):596–9.

    PubMed  Google Scholar 

  48. 48.

    Kaufmann J, Wolf AR, Becke K, Laschat M, Wappler F, Engelhardt T. Drug safety in paediatric anaesthesia. Br J Anaesth. 2017;118(5):670–9.

    CAS  PubMed  Google Scholar 

  49. 49.

    Koyama AK, Maddox CS, Li L, Bucknall T, Westbrook JI. Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Qual Saf. 2020;29(7):595–603.

    PubMed  Google Scholar 

  50. 50.

    Leung JS, Johnson DW, Sperou AJ, Crotts J, Saude E, Hartling L, et al. A systematic review of adverse drug events associated with administration of common asthma medications in children. PLoS ONE. 2017;12(8):e0182738.

    PubMed  PubMed Central  Google Scholar 

  51. 51.

    Melton KR, Ni Y, Tubbs-Cooley HL, Walsh KE. Using health information technology to improve safety in neonatal care: a systematic review of the literature. Clin Perinatol. 2017;44(3):583–616.

    PubMed  Google Scholar 

  52. 52.

    Patel NS, Patel TK, Patel PB, Naik VN, Tripathi CB. Hospitalizations due to preventable adverse reactions-a systematic review. Eur J Clin Pharmacol. 2017;73(4):385–98.

    PubMed  Google Scholar 

  53. 53.

    Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. J Am Med Inform Assoc (JAMIA). 2017;24(2):413–22.

    PubMed  Google Scholar 

  54. 54.

    Rush KL, Howlett L, Munro A, Burton L. Videoconference compared to telephone in healthcare delivery: a systematic review. Int J Med Inform. 2018;118:44–53.

    PubMed  Google Scholar 

  55. 55.

    Sutherland A, Phipps DL, Tomlin S, Ashcroft DM. Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review. BMC Pediatr. 2019;19(1):486.

    PubMed  PubMed Central  Google Scholar 

  56. 56.

    Wells M, Goldstein LN, Bentley A, Basnett S, Monteith I. The accuracy of the Broselow tape as a weight estimation tool and a drug-dosing guide-a systematic review and meta-analysis. Resuscitation. 2017;121:9–33.

    PubMed  Google Scholar 

  57. 57.

    York JB, Cardoso MZ, Azuma DS, Beam KS, Binney GG Jr, Weingart SN. Computerized physician order entry in the neonatal intensive care unit: a narrative review. Appl Clin Inform. 2019;10(3):487–94.

    PubMed  PubMed Central  Google Scholar 

  58. 58.

    Orwin RG. Evaluating coding decisions. In: Cooper H, Hedges LV, editors. The handbook of research synthesis. New York: Russell Sage Foundation; 1994. p. 139–62.

    Google Scholar 

  59. 59.

    Chedoe I, Molendijk HA, Dittrich ST, Jansman FG, Harting JW, Brouwers JR, et al. Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety: a review of the current literature. Drug Saf. 2007;30(6):503–13.

    PubMed  Google Scholar 

  60. 60.

    Sanghera N, Chan PY, Khaki ZF, Planner C, Lee KK, Cranswick NE, et al. Interventions of hospital pharmacists in improving drug therapy in children: a systematic literature review. Drug Saf. 2006;29(11):1031–47.

    PubMed  Google Scholar 

  61. 61.

    Higgins JPT, Altman DG, Sterne JAC. Chapter 8: Assessing risk of bias in included studies. In: Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions: the Cochrane Collaboration; 2011.

  62. 62.

    Sterne JA, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ (clinical research ed). 2016;12(355):i4919.

    Google Scholar 

  63. 63.

    Moher D, Jadad AR, Nichol G, Penman M, Tugwell P, Walsh S. Assessing the quality of randomized controlled trials: an annotated bibliography of scales and checklists. Control Clin Trials. 1995;16(1):62–73.

    CAS  PubMed  Google Scholar 

  64. 64.

    Hierarchy of controls. The National Institute for Occupational Safety and Health (NIOSH). 2015. Accessed 22 Dec 2020.

  65. 65.

    Cohen J. A power primer. Psychol Bull. 1992;112(1):155–9.

    CAS  PubMed  Google Scholar 

  66. 66.

    Stern JM, Simes RJ. Publication bias: evidence of delayed publication in a cohort study of clinical research projects. BMJ (clinical research ed). 1997;315(7109):640–5.

    CAS  PubMed Central  Google Scholar 

  67. 67.

    Hopewell S, Loudon K, Clarke MJ, Oxman AD, Dickersin K. Publication bias in clinical trials due to statistical significance or direction of trial results. Cochrane Database Syst Rev. 2009;21(1):Mr000006.

  68. 68.

    Ioannidis JP. Effect of the statistical significance of results on the time to completion and publication of randomized efficacy trials. JAMA. 1998;279(4):281–6.

    CAS  PubMed  Google Scholar 

  69. 69.

    Reyes MM, Panza KE, Martin A, Bloch MH. Time-lag bias in trials of pediatric antidepressants: a systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2011;50(1):63–72.

    PubMed  Google Scholar 

  70. 70.

    Abuelsoud N. Pharmacy quality improvement project to enhance the medication management process in pediatric patients. Ir J Med Sci. 2019;188(2):591–600.

    CAS  PubMed  Google Scholar 

  71. 71.

    Adelman J, Aschner J, Schechter C, Angert R, Weiss J, Rai A, et al. Use of temporary names for newborns and associated risks. Pediatrics. 2015;136(2):327–33.

    PubMed  Google Scholar 

  72. 72.

    Adelman JS, Aschner JL, Schechter CB, Angert RM, Weiss JM, Rai A, et al. Evaluating serial strategies for preventing wrong-patient orders in the NICU. Pediatrics. 2017;139(5).

  73. 73.

    Aseeri MA. The impact of a pediatric antibiotic standard dosing table on dosing errors. J Pediatric Pharmacol Therap (JPPT). 2013;18(3):220–6.

    Google Scholar 

  74. 74.

    Benkelfat R, Gouin S, Larose G, Bailey B. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013;45(3):419–25.

    PubMed  Google Scholar 

  75. 75.

    Booth R, Sturgess E, Taberner-Stokes A, Peters M. Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit. Intensive Care Med. 2012;38(11):1858–67.

    PubMed  Google Scholar 

  76. 76.

    Bruce K, Hall L, Castelo S, Evans M, Frangoul H. Direct provider feedback to decrease chemotherapy ordering errors: the “gray envelope” initiative. Pediatr Blood Cancer. 2012;59(7):1330–1.

    PubMed  Google Scholar 

  77. 77.

    Condren M, Honey BL, Carter SM, Ngo N, Landsaw J, Bryant C, et al. Influence of a systems-based approach to prescribing errors in a pediatric resident clinic. Acad Pediatrics. 2014;14(5):485-90.

  78. 78.

    Dharmar M, Kuppermann N, Romano PS, Yang NH, Nesbitt TS, Phan J, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics. 2013;132(6):1090–7.

    PubMed  Google Scholar 

  79. 79.

    Donnelly P, Lawson S, Watterson C. Improving paediatric prescribing practice in a district general hospital through implementation of a quality improvement programme. BMJ Qual Improve Rep. 2015;4(1).

  80. 80.

    Ernst KD. Electronic alerts improve immunization rates in two-month-old premature infants hospitalized in the neonatal intensive care unit. Appl Clin Inform. 2017;8(1):206–13.

    PubMed  PubMed Central  Google Scholar 

  81. 81.

    Fawaz MG, Sabri NA, Albaghdady AA, Malek FAA. Detection and prevention of medication errors in the operating rooms of a pediatric surgery department in Egypt. Int J Pharmaceut Sci Rev Res. 2017;42(2):100–6.

    Google Scholar 

  82. 82.

    Foster ME, Lighter DE, Godambe AV, Edgerson B, Bradley R, Godambe S. Effect of a resident physician educational program on pediatric emergency department pharmacy interventions and medication errors. J Pediatric Pharmacol Therap (JPPT). 2013;18(1):53–62.

    Google Scholar 

  83. 83.

    Garg M, Swab M, Gibney D, Cohen J, Gupta N, Ooi CY. Influence of dietitians in preventing parenteral nutrition prescription errors in children. JPEN J Parenter Enteral Nutr. 2018;42(3):607–12.

    PubMed  Google Scholar 

  84. 84.

    Garner SS, Cox TH, Hill EG, Irving MG, Bissinger RL, Annibale DJ. Prospective, controlled study of an intervention to reduce errors in neonatal antibiotic orders. J Perinatol. 2015;35(8):631–5.

    CAS  PubMed  Google Scholar 

  85. 85.

    Gazarian M, Graudins LV. Long-term reduction in adverse drug events: an evidence-based improvement model. Pediatrics. 2012;129(5):e1334–42.

    PubMed  Google Scholar 

  86. 86.

    Gordon M, Bose-Haider B. A novel system of prescribing feedback to reduce errors: a pilot study. Int J Risk Saf Med. 2012;24(4):207–14.

    PubMed  Google Scholar 

  87. 87.

    Haas-Gehres A, Sebastian S, Lamberjack K. Impact of pharmacist integration in a pediatric primary care clinic on vaccination errors: a retrospective review. J Am Pharm Assoc (JAPhA). 2014;54(4):415-8.

  88. 88.

    Hou J, Cheng K, Bai K, Chen H, Wu W, Lin Y, et al. The effect of a computerized pediatric dosing decision support system on pediatric dosing errors. J Food Drug Anal. 2013;21(3):286–91.

    Google Scholar 

  89. 89.

    Jozefczyk KG, Kennedy WK, Lin MJ, Achatz J, Glass MD, Eidam WS, et al. Computerized prescriber order entry and opportunities for medication errors: comparison to tradition paper-based order entry. J Pharm Pract. 2013;26(4):434–7.

    PubMed  Google Scholar 

  90. 90.

    Kadam RM, Gohil B, Kabra NS, Ahmed J, Avasthi BS, Sharma SR. Prescription errors in NICU: prevalence and results of an intervention program. Perinatology. 2018;19(1):29–35.

    Google Scholar 

  91. 91.

    Karande IS, Goff Z, Kewley J, Mehta S, Snelling T. Dose-banding of intravenous piperacillin-tazobactam in pediatric surgical inpatients. J Pediatric Pharmacol Therap (JPPT) 2017;22(5):364-8.

  92. 92.

    Kaufmann J, Roth B, Engelhardt T, Lechleuthner A, Laschat M, Hadamitzky C, et al. Development and prospective federal state-wide evaluation of a device for height-based dose recommendations in prehospital pediatric emergencies: a simple tool to prevent most severe drug errors. Prehospital Emerg Care. 2016;07:1–8.

    Google Scholar 

  93. 93.

    Keiffer S, Marcum G, Harrison S, Teske DW, Simsic JM. Reduction of medication errors in a pediatric cardiothoracic intensive care unit. J Nurs Care Qual. 2015;30(3):212-9.

  94. 94.

    Leach ME, Pasha N, McKinnon K, Etheridge L. Quality improvement project to reduce paediatric prescribing errors in a teaching hospital. Arch Dis Child Educ Pract Ed. 2016;101(6):311–5.

    PubMed  Google Scholar 

  95. 95.

    Lepee C, Klaber RE, Benn J, Fletcher PJ, Cortoos PJ, Jacklin A, et al. The use of a consultant-led ward round checklist to improve paediatric prescribing: an interrupted time series study. Eur J Pediatr. 2012;171(8):1239–45.

    PubMed  Google Scholar 

  96. 96.

    Maaskant JM, Tio MA, van Hest RM, Vermeulen H, Geukers VGM. Medication audit and feedback by a clinical pharmacist decrease medication errors at the PICU: an interrupted time series analysis. Health Sci Rep. 2018;1(3):e23.

    PubMed  PubMed Central  Google Scholar 

  97. 97.

    Maat B, Rademaker CM, Oostveen MI, Krediet TG, Egberts TC, Bollen CW. The effect of a computerized prescribing and calculating system on hypo- and hyperglycemias and on prescribing time efficiency in neonatal intensive care patients. JPEN J Parenter Enteral Nutr. 2013;37(1):85–91.

    CAS  PubMed  Google Scholar 

  98. 98.

    Martin LD, Grigg EB, Verma S, Latham GJ, Rampersad SE, Martin LD. Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia. Paediatr Anaesth. 2017;27(6):571–80.

    PubMed  Google Scholar 

  99. 99.

    Martinez-Anton A, Sanchez JI, Casanueva L. Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit. Intensive Care Med. 2012;38(9):1532–8.

    PubMed  Google Scholar 

  100. 100.

    McClead RE Jr, Catt C, Davis JT, Morvay S, Merandi J, Lewe D, et al. An internal quality improvement collaborative significantly reduces hospital-wide medication error related adverse drug events. J Pediatr. 2014;165(6):1222-9.e1.

    PubMed  Google Scholar 

  101. 101.

    Mekory TM, Bahat H, Bar-Oz B, Tal O, Berkovitch M, Kozer E. The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation. Int J Qual Health Care. 2017;29(3):366–70.

    PubMed  Google Scholar 

  102. 102.

    Merino Sanjuan M, Chorro-Mari V, Nwokoro C, Christiansen N, Pao C, Gomez-Pastrana Duran D, et al. Quality improvement project to evaluate discharge prescriptions in children with cystic fibrosis. Pediatric Qual Saf. 2019;4(5):e208.

  103. 103.

    Migowa AN, Macharia WM, Samia P, Tole J, Keter AK. Effect of a voice recognition system on pediatric outpatient medication errors at a tertiary healthcare facility in Kenya. Therap Adv Drug Saf. 2018;9(9):499–508.

    Google Scholar 

  104. 104.

    Nomura Y, Garcia M, Child J, Hurst AL, Hyman D, Poppy A, et al. Effect of provider-selected order indications on appropriateness of antimicrobial orders in a pediatric hospital. Am J Health-Syst Pharm (AJHP). 2018;75(4):213–21.

    PubMed  Google Scholar 

  105. 105.

    Palmero D, Di Paolo ER, Beauport L, Pannatier A, Tolsa JF. A bundle with a preformatted medical order sheet and an introductory course to reduce prescription errors in neonates. Eur J Pediatr. 2016;175(1):113–9.

    PubMed  Google Scholar 

  106. 106.

    Rogers J, Pai V, Merandi J, Catt C, Cole J, Yarosz S, et al. Impact of a pharmacy student-driven medication delivery service at hospital discharge. Am J Health-Syst Pharm (AJHP). 2017;74(5 Supplement 1):S24–s9.

  107. 107.

    Russell RA, Triscari D, Murkowski K, Scanlon MC. Impact of computerized order entry to pharmacy interface on order-infusion pump discrepancies. J Drug Deliv. 2015;2015:686598.

    PubMed  PubMed Central  Google Scholar 

  108. 108.

    Sankar J, Das RR, Mahapatro S, Sankar MJ. Effect of a training strategy in improving medication fallacies during pediatric cardiopulmonary resuscitation: a before-and-after study from a developing country. Pediatr Emerg Care. 2019;35(4):278–82.

    PubMed  Google Scholar 

  109. 109.

    Sethuraman U, Kannikeswaran N, Murray KP, Zidan MA, Chamberlain JM. Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 2015;22(6):714–9.

    Google Scholar 

  110. 110.

    Sullivan KM, Suh S, Monk H, Chuo J. Personalised performance feedback reduces narcotic prescription errors in a NICU. BMJ Qual Saf. 2013;22(3):256–62.

    PubMed  Google Scholar 

  111. 111.

    Vairy S, Corny J, Jamoulle O, Levy A, Lebel D, Carceller A. Can a two-hour lecture by a pharmacist improve the quality of prescriptions in a pediatric hospital? A retrospective cohort study. Canmed Educ J. 2017;8(4):e6–15.

    Google Scholar 

  112. 112.

    Venkataraman A, Siu E, Sadasivam K. Paediatric electronic infusion calculator: an intervention to eliminate infusion errors in paediatric critical care. J Intensive Care Soc. 2016;17(4):290–4.

    PubMed  PubMed Central  Google Scholar 

  113. 113.

    Watts RG, Parsons K. Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate. Pediatr Blood Cancer. 2013;60(8):1320–4.

    PubMed  Google Scholar 

  114. 114.

    Weddle G, Goldman J, Myers A, Newland J. Impact of an educational intervention to improve antibiotic prescribing for nurse practitioners in a pediatric urgent care center. J Pediatric Health. 2017;31(2):184–8.

  115. 115.

    Wise KA, Sebastian SJ, Haas-Gehres AC, Moore-Clingenpeel MD, Lamberjack KE. Pharmacist impact on pediatric vaccination errors and missed opportunities in the setting of clinical decision support. J Am Pharm Assoc (JAPhA). 2017;57(3):356–61.

  116. 116.

    Liberati EG, Peerally MF, Dixon-Woods M. Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare. Int J Qual Health Care. 2018;30(1):39–43.

    PubMed  Google Scholar 

  117. 117.

    Gray JE, Suresh G, Ursprung R, Edwards WH, Nickerson J, Shiono PH, et al. Patient misidentification in the neonatal intensive care unit: quantification of risk. Pediatrics. 2006;117(1):e43–7.

    PubMed  Google Scholar 

  118. 118.

    Bates DW, Singh H. Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Affairs (Project Hope). 2018;37(11):1736–43.

    Google Scholar 

  119. 119.

    Blumenthal D. Launching HITECH. N Engl J Med. 2010;362(5):382–5.

    CAS  PubMed  Google Scholar 

  120. 120.

    Adler-Milstein J, Holmgren AJ, Kralovec P, Worzala C, Searcy T, Patel V. Electronic health record adoption in US hospitals: the emergence of a digital “advanced use” divide. J Am Med Inform Assoc (JAMIA). 2017;24(6):1142–8.

    PubMed  PubMed Central  Google Scholar 

  121. 121.

    Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2016. Am J Health Syst Pharm. 2017;74(17):1336–52.

    PubMed  Google Scholar 

  122. 122.

    Henry J, Pylypchuk Y, Searcy T., Patel V. Adoption of electronic health record systems among U.S. Non-Federal Acute Care Hospitals: 2008-2015. ONC data brief, no.35. 2016. The Office of the National Coordinator for Health Information Technology. Accessed 22 Dec 2020.

  123. 123.

    Panning J, Doerje F. Strategien zur Verbesserung der Arzneimitteltherapiesicherheit. Krankenhauspharmazie. 2018;39(3):81–8.

    Google Scholar 

  124. 124.

    Results of the 2014 Leapfrog hospital survey: computerized physician order entry. The Leapfrog Group. 2014. Accessed 12 Nov 2020.

  125. 125.

    Hussain MI, Reynolds TL, Zheng K. Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review. J Am Med Inform Assoc (JAMIA). 2019;26(10):1141–9.

    PubMed  PubMed Central  Google Scholar 

  126. 126.

    McGreevey JD 3rd, Mallozzi CP, Perkins RM, Shelov E, Schreiber R. Reducing alert burden in electronic health records: state of the art recommendations from four health systems. Appl Clin Inform. 2020;11(1):1–12.

    PubMed  PubMed Central  Google Scholar 

  127. 127.

    Plan, Do, Study, Act (PDSA) cycles and the model for improvement. NHS Improvement. 2018. Accessed 22 Dec 2020.

  128. 128.

    Card AJ, Ward J, Clarkson PJ. Successful risk assessment may not always lead to successful risk control: A systematic literature review of risk control after root cause analysis. J Healthc Risk Manag. 2012;31(3):6–12.

    PubMed  Google Scholar 

  129. 129.

    Sutherland A, Ashcroft DM, Phipps DL. Exploring the human factors of prescribing errors in paediatric intensive care units. Arch Dis Child. 2019;104(6):588–95.

    PubMed  PubMed Central  Google Scholar 

  130. 130.

    Morrison A, Polisena J, Husereau D, Moulton K, Clark M, Fiander M, et al. The effect of English-language restriction on systematic review-based meta-analyses: a systematic review of empirical studies. Int J Technol Assess Health Care. 2012;28(2):138–44.

    PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Joachim A. Koeck.

Ethics declarations


This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Conflict of interest

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

Availability of data and material

Not applicable.

Code availability

Not applicable.

Ethics approval

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

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Author contributions

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.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 297 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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).

Download citation