How to avoid paediatric medication errors: a user's guide to the literature

Abstract

The National Health Service, in its report An organisation with memory, has called for a fundamental rethinking of the way the healthcare system learns from error. The NHS further details its goal to reduce serious medication errors by 40% in a second report entitled Building a safer NHS: improving medication safety. This report calls for a review of paediatric medication delivery systems to assess safety for children.

Figure 1

Diagram illustrating the distinction between adverse drug events and medication errors.

Figure 2

Series of steps from ordering to patient receiving medication with a paper based ordering system.