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Factors associated with medication administration errors in hospitalized pediatric patients: A scoping review
Claudia Lorena Motta Robayo1, Jonathan Martínez Pinto1, Bryan Tabango Goyes1
1Facultad de Enfermería, Universidad Nacional de Colombia, Bogotá, Colombia.
Insights
Medication errors in hospitalized children are common, often due to incorrect dosing and human factors. Prevention requires integrated strategies like education, technology, and a non-punitive safety culture to protect vulnerable pediatric patients.
Area of Science:
- Pediatric Patient Safety
- Medication Administration
- Healthcare Quality Improvement
Background:
- Medication errors are a significant cause of preventable harm in hospitalized children.
- The pediatric population faces unique risks due to dosing variability and developmental factors.
Purpose of the Study:
- To synthesize evidence on factors contributing to medication administration errors in pediatric inpatients.
- To identify effective strategies for preventing these errors.
Main Methods:
- Systematic review of 25 studies (quantitative, qualitative, mixed methods) published in English, Spanish, or Portuguese.
- Searched nine databases and reference lists; followed Joanna Briggs Institute (JBI) methodology.
- Employed narrative synthesis with thematic analysis for data interpretation.
Main Results:
- Incorrect dosing was the most frequent error type (72% of studies).
- Neonates and infants in PICU/NICU settings were most vulnerable.
- Human factors, especially knowledge deficits (52% of studies), were key contributors.
Conclusions:
- Pediatric medication errors result from complex interactions of human, environmental, and medication-related factors.
- Integrated prevention strategies including education, technology, and a non-punitive safety culture are essential.
Background:
Medication errors are a leading preventable cause of harm in hospitalized children. The pediatric population is particularly vulnerable due to weight-based dosing requirements, developmental pharmacokinetic variability, and limited capacity for self-advocacy.
Objectives:
To map and synthesize the available evidence on factors associated with the occurrence of medication administration errors in hospitalized pediatric patients.
Eligibility Criteria:
Studies addressing administration phase medication errors (per the National Coordinating Council for Medication Error Reporting and Prevention, NCC MERP) in hospitalized children aged 0 to 18 years, published in English, Spanish, or Portuguese, using quantitative, qualitative, or mixed methods designs.
Sources Of Evidence:
Nine electronic databases were searched from inception to July 2026 using English, Spanish, and Portuguese (DeCS) terms, supplemented by hand searching of reference lists.
Charting Methods:
The review followed the Joanna Briggs Institute (JBI) methodology; data were charted with the JBI standardized instrument and synthesized narratively with thematic analysis.
Results:
Of 1,012 records, 25 studies met the inclusion criteria. Incorrect dosing was the most prevalent error type (18 studies, 72%). Neonates and infants were the most vulnerable group, and PICU and NICU the highest-risk settings, although a direct observation study reported that 37% of administrations on general wards involved an error. Human factors, particularly knowledge deficits, were the most frequently reported contributors (13 studies, 52%). Five complementary mitigation strategies were identified: professional education, dual verification, unified non-punitive reporting, technology, and interprofessional communication.
Conclusions:
Medication administration errors in pediatric inpatients are driven by a multilayered interplay of human, environmental, communicative, and medication related factors. Effective prevention demands integrated, systems-based approaches combining education, technology, standardized protocols, and a non-punitive safety culture.
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