Increasing Age as a Risk Factor for Medication Errors in Children

Source: Badgery-Parker T, Li L, Fitzpatrick E, et al. Child age and risk of medication error: a multisite children’s hospital study. J Pediatr. 2024;272:114087; doi: 10.1016/j.jpeds.2024.114087.Investigators from Macquarie University, Sydney, Australia, conducted a retrospective study to assess the association between patient age and medication errors in hospitalized children. The data analyzed originally were collected as part of a study looking at the effect of the introduction of electronic medication management and medication errors. In that study, medication orders were reviewed to identify prescribing errors, and direct observation of nurses administering drugs was used to evaluate administration errors. Data were collected at 2 large academic pediatric hospitals in Australia during the period 2016–2020. For the current study, the association between prescribing errors, administration errors, and patient age were analyzed separately using various statistical techniques. Subgroup analyses were performed to evaluate the association between potentially serious prescribing errors and child age as well as type of prescribing error and age. Subgroup analyses for administration errors were performed for oral medications, intravenous (IV) infusions, and IV injections.A total of 68,781 medication orders for 8,691 patients were assessed for prescribing errors. The overall rate of prescribing errors was 18.6 errors per 100 orders. The rate of prescribing errors increased with patient age up until age 12 years, then leveled off. For children <1 year old, the rate of prescribing errors was 16.0 per 100 orders (95% confidence interval [CI], 15.2, 16.9) compared to 20.9 per 100 orders (95% CI, 20.3, 21.6) in those ≥12 years old. Overall, the rate of prescribing errors increased significantly with age (P <0.001). The rate of potentially serious prescribing errors also increased with patient age (P <0.001). The most frequent type of prescribing error was wrong dose, accounting for 45.3% of prescribing errors. The rate of wrong dose prescribing errors increased with patient age (P = 0.003). Among 5,137 observed medication administrations to 1,530 patients, 1 or more administration errors was noted in 1,858 (36.2%) cases. In a multivariate regression model, the number of medication administration errors increased significantly with age (P = 0.001). The number of administration errors for oral medications also increased with increasing patient age (P = 0.01), but there was not a significant association between patient age and number of administration errors for IV infusions (P = 0.23). For IV injections, there was a U-shaped association between errors and age, with rates highest in the youngest and oldest patients.The authors conclude that the risk of medication errors in hospitalized children increased with increasing patient age.Dr Loyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.More than 2 decades ago, the Institute of Medicine’s Committee on Quality of Health Care in America comprehensive report on the problem of medical errors in health care systems, was a call to action for improvements in patient safety and quality.1 Results of the current study indicate much work is still needed. In a secondary analysis of a rollout of electronic medication management on the general inpatient units of 2 Australian pediatric hospitals, investigators found that increased age was associated with an increased risk for medication error in hospitalized children.Among 15 categories of potential medication errors, dosing errors were the most frequent when prescribed or administered. Prescribing errors can be interlinked and, specifically in pediatrics, are influenced by individualized dosing and calculations, medication formulations, communication with children, experience working with children, and off-license prescribing.2 The role of pediatric-trained pharmacists as a critical layer of safety cannot be understated. Pharmacists have been shown to identify and correct medication errors before they reach children.3 However, justifying the financial need for pediatric-trained pharmacy staff in settings where not all patients are children remains problematic.4The authors of the current study surmise that older children may be prescribed more medications that could conceivably increase the risk of error or that childhood obesity, more apparent in older children, may result in weight-based doses that are erroneous. Details on the patient profile outside of age that might be associated with medication errors, such as acuity and medical complexity, would be informative. Within dosing errors, the current investigators also report that infants in their study were more likely to be underdosed and overdoses increased with age. Clinical decision support and dose calculators embedded in the electronic medical record are supposed to help with calculations, but investigators caution that dose calculators may round up or down to the nearest whole number and inadvertently cause a dosing error.Medication errors in children hospitalized on general pediatric wards are associated with increasing patient age.