The role of advice in medication administration errors in the pediatric ambulatory setting

J Patient Saf. 2009 Sep;5(3):168-75. doi: 10.1097/PTS.0b013e3181b3a9b0.


Background: In the pediatric setting, adverse events occurring at the administration stage are the most common type of preventable adverse drug events. Few data are available on the effect of advice from medical professionals on medication safety.

Methods: This is a prospective cohort study of 1685 pediatric patients, 6 office practices in the Boston area. Data were collected from parental interviews, review of duplicate prescriptions, and chart review. Incidents were stratified by type (medication error, near miss, or preventable adverse drug event) and stage of the medication process. Descriptive analysis was followed by a multivariable analysis to determine which factors influenced the occurrence of reported medication administration errors.

Results: Advice from both office and pharmacy was assessed to be poor in quality and limited in provision. Health care providers most often failed to offer information. Fifty-seven percent of families who did not receive information were not presented with information, rather than refusing it. Multivariable analysis did not demonstrate that advice form or location reduced the rate of medication administration errors (errors occurring during delivery of the medication, usually in the home). However, taking more than 1 medication (odds ratio = 1.68; 95% confidence interval, 1.15-2.46) and age younger than 5 years (odds ratio = 2.35; 95% confidence interval, 1.05-5.28) were correlated with risk of a medication administration error.

Conclusions: Inadequate advice was provided. The current approach for delivering advice does not prevent against medication administration errors. Those at highest risk of such errors are the youngest children and those on multiple medications.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Ambulatory Care Facilities*
  • Boston
  • Child
  • Child, Preschool
  • Cohort Studies
  • Female
  • Humans
  • Interviews as Topic
  • Male
  • Medical Audit
  • Medication Errors / prevention & control*
  • Multivariate Analysis
  • Pediatrics*
  • Prospective Studies
  • Safety Management