Related Experiment Video
Updated: Dec 1, 2025

Improving IV Insulin Administration in a Community Hospital
Published on: June 11, 2012
Prevalence of medication discrepancies in pediatric patients transferred between hospital wards
Thaciana Dos Santos Alcântara1, Fernando Castro de Araújo Neto1, Helena Ferreira Lima1
1Pharmaceutical Sciences Graduate Program, Laboratory of Teaching and Research in Social Pharmacy (LEPFS-UFS), Federal University of Sergipe, São Cristóvão, Brazil.
Insights
Pediatric medication errors are common during care transitions, especially at discharge. Omission of medication was the most frequent unintentional error found in this study.
Area of Science:
- Pediatric Pharmacology
- Patient Safety
- Healthcare Transitions
Background:
- Children face higher risks from medication errors and adverse drug reactions than adults.
- Medication discrepancies during healthcare transitions contribute to these risks.
- Lack of information and medication discontinuity are key contributing factors.
Purpose of the Study:
- To determine the frequency of medication discrepancies at care transition points in a pediatric unit.
- To analyze the types of medication discrepancies identified.
Main Methods:
- A cross-sectional study was conducted in a pediatric department from August 2017 to March 2018.
- Data included sociodemographic information, caregiver interviews, prescription review, and medical record evaluation.
- Medication discrepancies were categorized as intentional or unintentional (omission, duplication, dose/frequency/route differences).
Main Results:
- 85% of 114 pediatric patients experienced at least one unintentional medication discrepancy.
- Discrepancies were most prevalent at hospital discharge (45.6%) and internal transfer (36.8%).
- Omission of medication was the most common unintentional discrepancy, particularly at discharge (100%).
Conclusions:
- Internal transfer and hospital discharge are critical points for unintentional medication discrepancies in pediatric care.
- Medication omission is the predominant type of unintentional error, highlighting a significant patient safety concern.
- Interventions targeting medication reconciliation at these transition points are crucial for improving pediatric patient safety.
Abstract:
Background Children are more susceptible to harm from medication errors and adverse drug reactions when compared to adults. Such events may occur from medication discrepancies while transitioning patients throughout the healthcare system. Contributing factors include medication discontinuity and lack of information by the healthcare team. Objective To analyze the prevalence of medication discrepancies in transition points of care in a pediatric department. Setting Pediatric department of a public hospital in Northeast Brazil. Method A cross-sectional study was carried out from August 2017 to March 2018. Data collection consisted of the following steps: collection of sociodemographic data, clinical interview with the patient's caregiver, registration of patient prescriptions, and evaluation of medical records. Medication discrepancies were classified as intentional and unintentional. The unintentional medication discrepancies were classified as omission of medication, therapeutic duplicity, and differences in dose, frequency, or route of administration. Main outcomes measure Discrepancy profile identified at admission, internal transfer and hospital discharge. Results Among the 114 patients included in the study, 85 (74.5%) patients had at least one unintentional medication discrepancy, of which 16 (14.0%) patients presented medication discrepancies at hospital admission, 42 (36.8%) patients at internal transfer, and 52 (45.6%) patients during discharge. Omission of medication represented 20 (74.1%) errors at admission, 26 (37.7%) errors at internal transfer, and 80 (100.0%) errors at hospital discharge. Conclusions The main transition points of care where unintentional discrepancies occurred in the studied pediatric department were at internal transfer and hospital discharge, with omission being the most common type of unintentional discrepancy.
More Related Videos
Related Concept Videos
Drug Dosing: Infants and Children
Pharmacokinetics in Pediatric Patients: Drug Excretion
Pharmacokinetics in Pediatric Patients: Drug Distribution
Pharmacokinetics in Pediatric Patients: Overview and Drug Absorption
Drug Dosing: Geriatric Patients
Pharmacokinetics in Pediatric Patients: Drug Metabolism

