Color coded medication safety system reduces community pediatric emergency nursing medication errors

J Patient Saf. 2009 Jun;5(2):79-85. doi: 10.1097/PTS.0b013e3181a647ab.


Objectives: To compare the performance of current systems in place for preparation and administration of pediatric medications in community emergency departments to the color-coded medication safety (CCMS) system among nurses.

Methods: Community ED nurses participated in simulated pediatric emergency scenarios using traditional dosing references then the CCMS system. We measured preintervention/postintervention: (1) time to task completion from physician order to medication administration; (2) accuracy of conversion to milliliters, dilution, and time for medication administration; and (3) recognition of 10-fold physician errors.

Results: A total of 320 medication and infusion orders were given to 16 nurses. The median time to task completion preintervention was 109 seconds (interquartile range, 44-626). Time to task completion was reduced to a median of 28 seconds (interquartile range, 14-43; P < 0.001) with the CCMS system. Significant error reductions were noted when nurses used the CCMS system: 25.6% of medications were converted incorrectly compared with 2.5% with the system, a 23% improvement (95% confidence interval [CI], 13-33; P < 0.001), 35.6% were diluted incorrectly compared with 0.63%, a 35% improvement (95% CI, 26-44; P < 0.001), and 54.7% were administered incorrectly compared with 3.9%, a 51% improvement (95% CI, 39-61; P < 0.001). Only 20% of 10-fold physician order errors were recognized preintervention but 93% were recognized using the CCMS system, a 73% improvement.

Conclusions: The CCMS system reduces pediatric medication delay and improves nursing accuracy. This is important in the community ED setting where many children receive emergency care and where providers may lack familiarity with pediatric medication dosing.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child
  • Color
  • Emergency Service, Hospital*
  • Hospitals, Community*
  • Humans
  • Medication Errors / nursing*
  • Medication Errors / prevention & control*
  • Medication Systems, Hospital / organization & administration*
  • Pediatric Nursing