YJPDN-02607; No of Pages 9

Journal of Pediatric Nursing xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

journal homepage: www.pediatricnursing.org

Nursing interventions to reduce medication errors in paediatrics

and neonates: Systematic review and meta-analysis
Takawira C. Marufu, RN, BSc, MPH, PhD a,⁎, Rachel Bower, RN, BSc, MSc a,
Elizabeth Hendron, BSc b, Joseph C. Manning, RN, MNursSci, PGCert, PhD a,c
a
Nottingham Childrens Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
b
Library Services, Nottingham University Hospitals NHS Trust, Nottingham, UK
c
Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK

a r t i c l e i n f o a b s t r a c t

Article history: Background: Medication errors are a great concern to health care organisations as they are costly and pose a sig-
Received 28 May 2021 nificant risk to patients. Children are three times more likely to be affected by medication errors than adults with
Revised 26 August 2021 medication administration error rates reported to be over 70%.
Accepted 27 August 2021 Objective: To identify nursing interventions to reduce medication administration errors and perform a meta-
Available online xxxx
analysis.
Methods: Online databases; British Nursing Index (BNI), Cochrane Database of Systematic Reviews, Cumulative
Keywords:
Paediatrics
Index to Nursing and Allied Health Literature (CINAHL), EMBASE and MEDLINE were searched for relevant stud-
Neonates ies published between January 2000 to 2020. Studies with clear primary or secondary aims focusing on interven-
Medication tions to reduce medication administration errors in paediatrics, children and or neonates were included in the
Errors review.
Results: 442 studies were screened and18 studies met the inclusion criteria. Seven interventions were identified
from included studies; education programmes, medication information services, clinical pharmacist involve-
ment, double checking, barriers to reduce interruptions during drug calculation and preparation, implementation
of smart pumps and improvement strategies. Educational interventional aspects were the most common identi-
fied in 13 out of 18 included studies. Meta-analysis demonstrated an associated 64% reduction in medicine ad-
ministration errors post intervention (pooled OR 0.36 (95% Confidence Interval (CI) 0.21–0.63) P = 0.0003).
Conclusion: Medication safety education is an important element of interventions to reduce administration er-
rors. Medication errors are multifaceted that require a bundle interventional approach to address the complex-
ities and dynamics relevant to the local context. It is imperative that causes of errors need to be identified
prior to implementation of appropriate interventions.
© 2021 Elsevier Inc. All rights reserved.

Introduction
Medication errors, be it prescribing, preparation and dispensing, ad-
ministration or monitoring are key patient safety concerns and a quality
measure of healthcare medication process management. When they
occur, medication errors produce a variety of problems for patients,
ranging from minor discomfort to substantial morbidity that may lead
to increased length of hospital stay or death under certain circum-
stances (Stucky, 2003). An estimated 18.7% - 56% of all adverse events
among hospitalised patients result from preventable medication errors
(von Laue et al., 2003), however even more significant to realise is that
⁎ Corresponding author at: Clinical Academic Lead Nursing Research, Nottingham
Children's Hospital and Neonatology, Queens Medical Centre, C Floor South Block,
Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
E-mail address: takawira.marufu@nuh.nhs.uk (T.C. Marufu).
medication errors can occur in the absence of injury to the patient. The
National Coordinating Council for Medication Error Reporting and Pre-
vention (NCC MERP, 2020) described medication errors as ‘any prevent-
able event that may cause or lead inappropriate medication use or patient
harm while medication is in the control of healthcare professional, patient
or consumer’, demonstrating that medication errors occur as a result of
human mistakes or system flaws (Stucky, 2003). For these reasons
and more, in 2017 the World Health Organisation launched a global ini-
tiative aiming at reducing medication errors by 50% within a 5 year time
span (Bonner, 2017).
The paediatric and neonatal patient population are three times more
likely to be affected by medication errors than adults (Kaushal et al.,
2001; Simpson et al., 2004), and significantly higher error rates have
been reported during prescribing and administration in comparison to
dispensing and monitoring (Kaushal et al., 2001; Krähenbühl-Melcher
et al., 2007; Ross et al., 2000). Medication prescribing and administration

https://doi.org/10.1016/j.pedn.2021.08.024
0882-5963/© 2021 Elsevier Inc. All rights reserved.

Please cite this article as: T.C. Marufu, R. Bower, E. Hendron, et al., Nursing interventions to reduce medication errors in paediatrics and neonates:
Systematic review and..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2021.08.024
T.C. Marufu, R. Bower, E. Hendron et al.
error rates have been reported in various studies ranging from 3 to 37%
and 72–78% respectively (Bannan & Tully, 2016; Elliott et al., 2018).
Implementation of drug therapy in children and infants can be com-
plex due to one or more of the following; (i) treatment of rare and life-
threatening conditions requiring continuous adjustment of dosing and
drug therapy, (ii) narrow therapeutic range of some drugs, and (iii)
individualised dosing based on factors such as age, weight, renal func-
tions and maturation of enzyme systems (Bannan & Tully, 2016;
Niemann et al., 2014). Literature highlights that children are at greater
risk of harm than adults when medication errors occur (Chedoe et al.,
2012; Lindell-Osuagwu et al., 2009).
Due to the nature of errors, many studies have looked broadly at
interventions that looked at reducing errors across all healthcare pro-
fessionals' practice. There is a place for such interventions; however
nurses are at the forefront of medication administration where errors
are highest (reported to range from 72 to 78%) (Bannan & Tully, 2016;
Elliott et al., 2018), and it has been realised that administration errors
are the hardest to intercept causing direct harmful consequences for
patients (Buckley et al., 2007). Therefore the purpose of this review
was to comprehensively compile specific nursing interventions to
reduce drug administration errors and where applicable outline size
of effect.
Methods
Data sources
Five electronic databases were searched; British Nursing Index
(BNI), Cochrane Database of Systematic Reviews, Cumulative Index to
Nursing and Allied Health Literature (CINAHL), EMBASE and MEDLINE.
To maximise search sensitivity, a combination of various free text key
words and Medical Subject Headings (MeSH terms) were used. Search
terms included; paediatric, neonates, infants, babies, medication, drug,
error. Databases were searched from January 2000 to February 2020.
Study selection
The review considered peer reviewed published studies involved in
implementation of an intervention aimed at reducing medication ad-
ministration errors among nurses in in-patient paediatric clinical set-
tings. Children were defined as individuals between 0 and 18 years of
age. Papers published in other languages were considered if an English
translation was available. Excluded studies included case studies, epide-
miological studies, reviews, editorials and opinion papers.
Search strategy was performed by the hospital librarian with exten-
sive experience in literature searches. Two authors independently iden-
tified studies at abstract and full text stages. Disagreements on potential
studies for inclusion were resolved by discussion to reach consensus or
involvement of the third author.
Data extraction
Data extraction was performed independently by two authors using
a pre-piloted standardised form. The form sections included; author and
date of publication, study design, country of study, clinical setting type,
sample size, intervention implemented, pre and post- intervention out-
comes.
Methodology quality assessment
The quality Assessment Tool for Before and After (Pre-Post) studies
with No Control Group (BAQA) was used to assess the risk of bias of in-
cluded studies (National Heart Lung and Blood Institute, 2018). This was
calculated independently by two authors, any inconsistencies in scoring
of items were resolved through consensus.
2
Journal of Pediatric Nursing xxx (xxxx) xxx
Statistical analysis
Most included studies presented the results in percentages and error
rates. Using pre and post intervention total drug administration error
numbers, odds ratios (OR) and 95% confidence intervals (95% CI) for
the likelihood of medication error reduction after the intervention (ex-
posure) was calculated. A meta-analysis was performed in Rev. Man5
(Higgins & Green, 2019) using the random effect method for a pooled
size effect of implementing any error reduction intervention. For the
studies where OR could not be calculated, a qualitative synthesis is
given.
Results
Search process
Online searches identified 512 studies. After removal of duplicates
442 articles were screened at title and abstract stages. Nineteen studies
were assessed at full-text and 18 studies met the inclusion criteria and
were included for data extraction (Table 1 Characteristics of included
studies). Fig. 1 provides an overview of the search process.
Studies were conducted in seven countries. The majority of studies
(six) were from the USA (Colligan et al., 2012; Hebbar et al., 2018;
Kanjia et al., 2019; McSweeney et al., 2019; Subramanyam et al., 2016;
Yamamoto & Kanemori, 2010), three from Spain (Campino et al.,
2009; Campino et al., 2016; Manrique-Rodríguez et al., 2013), two
from Germany (Bertsche et al., 2010; Niemann et al., 2014) and one
from each of the following nations; Argentina, Canada, Malaysia,
Netherlands, Northern Ireland, Scotland (UK) and Saudi Arabia;
(Abuelsoud, 2019; Chedoe et al., 2012; Guérin et al., 2015; Otero et al.,
2008; Raja Lope et al., 2009; Simpson et al., 2004; Stewart et al., 2010).
Methodology quality assessment
All included studies in this paper clearly stated study objectives,
study population and the interventions. All studies were before and
after intervention studies. Sixteen studies were prospective cohort stud-
ies and one was a retrospective cohort (Guérin et al., 2015) and another
cross-sectional (Otero et al., 2008). Two studies (Colligan et al., 2012;
Stewart et al., 2010) rated moderate on risk of bias (25–75%) while
the rest rated low risk of bias. Randomisation and blinding of the asses-
sors was not possible due to the nature of the studies.
Outcomes
The studies looked at implementation of interventions to reduce
medication administration errors (MAEs) in specific individual paediat-
ric clinical areas or across the children's hospital as a whole. Six studies
were conducted in all specialties across children's hospitals (Colligan
et al., 2012; Guérin et al., 2015; Hebbar et al., 2018; McSweeney et al.,
2019; Otero et al., 2008), seven in NICU or PCCU only (Campino et al.,
2009; Campino et al., 2016; Chedoe et al., 2012; Manrique-Rodríguez
et al., 2013; Niemann et al., 2014; Raja Lope et al., 2009), two in paedi-
atric theatres (Kanjia et al., 2019; Subramanyam et al., 2016) and one in
an emergency department (Yamamoto & Kanemori, 2010) and one in a
paediatric neurological ward (Bertsche et al., 2010). One that looked at
interprofessional approach to improving paediatric medication safety
through interprofessional workshops to facilitate learning of knowledge
was conducted on fourth year medical students and third year nursing
students (Stewart et al., 2010).
Interventions
Seven individual interventions were identified from the included
studies (Appendix 1 Table 1 Summary of Interventions). These in-
cluded; education programs, drug information services (posters,
T.C. Marufu, R. Bower, E. Hendron et al. Journal of Pediatric Nursing xxx (xxxx) xxx

Table 1
Characteristics of included studies.

Author and year Country Type of study Participants Sample size (N) Interventions Results

Yamamoto & USA Prospective Nurses (Paediatric 38 computer-assisted vs conventional Mean conventional drug
Kanemori, 2010 cohort Emergency paediatric drug dosing and administration and dosing time
Department) administration 1243s vs mean computer program
total time of 879 s (P < 0.001),
Mean error 1.8 conventional method
vs 0.7 computer programme
(P < 0.001). OR 0.55 95% CI
(0.35–0.86)⁎.
Hebbar et al., 2018 USA Prospective Children's Hospital 1434 simulation training program Serious MAEs rates decreased from
cohort Nurses (general implementing MAE bundle (The 2.5 events per month during the
care units, Five Rights, Med-Zone, and 12-month pre-intervention period
emergency Independent Double Check) to 1.4 events per month during the
departments, and 20-month intervention rollout
intensive care (RR = 1.78, 95% CI = 1.03–3.1,
units) P = 0.029). MAEs further decreased
to 0.86 events per month during the
7-month post-intervention period
(RR = 2.9, 95% CI = 1.2–8.5,
P = 0.014) (63% decrease in MAEs
from the baseline period, with a 45%
drop in higher classified errors).
Colligan et al., 2012 USA Prospective Paediatric Specialty Single ward (20 Barriers to reduce interruptions Frequency of interruption: mean
observational (nurses) nurses) during drug calculation and interruption rate per minute of
preparation occurrence was significantly
reduced from 1.4 pre-intervention
to 0.27 post-intervention (paired
t-test = 5.7, df = 98, p < 0.01).
The length of time spent from
beginning to end of each occurrence
was not significantly reduced (120 s
vs 117 s pre-intervention and
post-intervention, respectively).
McSweeney et al., USA Prospective Paediatric Specialty 19 errors were improvement strategy included The number of therapy errors per
2019 cohort (nurses) analysed and several initiative(policy change, 1000 patient days fell from 19.28 in
deemed preventable change of process, education 2009 to 5.95 in 2016 (The CIPT error
by the SERS reporter programme, and hospital-wide rate decreased by 69% from 2009 to
safety initiatives) 2016). Chi2 analysis was used to
compare the result for 2009 with
that for each subsequent year, with
P values of 0.66, 0.35, 0.16, 0.09,
0.03, 0.12, and 0.25 found for 2010
through 2016, respectively.
Subramanyam et al., USA Prospective Children's Hospital 129 2-person verification system for During the intervention 4 errors
2016 study (anaesthetists and infusion pump programming before were rectified before the medication
nurses) medication administration was administered to the patient.
There was no delay in case starts
(>90% before and during the
project).The rate of 2-person
verification of infusion pump
programming increased from 0% to
90% and was sustained.
Kanjia et al., 2019 USA Prospective Paediatric 633 checklists and Education and Checklist tool The percentage of compliance with
cohort anaesthesia electronic medical the safe administration checklist for
(anaesthetists, records acetaminophen in the preoperative
physicians and period increased to 97%. Use of the
nurses) paper checklist likely prompted the
appropriate increase in compliance
with safe administration.
Additionally, provider-specific
feedback produced a significant
increase in compliance with use of
the checklist.
Campino et al., 2009 Spain Prospective NICU (doctors, 94 Education strategy Post-intervention prescription error
cohort nurses, nurses' aids rate and the percentage of registers
and pharmacists) with one or more incident decreased
significantly from 20.7 to 3%
(p < 0.001) and from 19.2 to 2.9%
(p < 0.001), respectively. OR 0.12
95% CI (0.09–0.16)⁎
Manrique-Rodríguez Spain Prospective PICU (nurses) 97 alarms associated implementing smart infusion pumps 92 programming errors with
et al., 2013 observational with real potentially harm to the patient were
interventional programming errors intercepted (84% of errors involved
analgesics, anti-infectives,
inotropes, and sedatives, 97% of the

(continued on next page)

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T.C. Marufu, R. Bower, E. Hendron et al. Journal of Pediatric Nursing xxx (xxxx) xxx

Table 1 (continued)

Author and year Country Type of study Participants Sample size (N) Interventions Results

errors resulted from user

programming of doses or infusion
rates above the hard limits defined
in the smart pump drug library,
potential consequences of the
intercepted errors were considered
to be of moderate, serious, or
catastrophic severity in 49% of cases.
Campino et al., 2009 Spain Prospective NICU (doctors, 10 Spanish neonatal educational and protocol In NICU, 1.35% of samples registered
observational nurses and intensive care units standardisation programme calculation errors in
study pharmacists) and one hospital pre-intervention phase; no
pharmacy service calculation errors were registered in
participated in the hospital pharmacy service (HPS)
study samples. In post-intervention phase,
no calculation errors were
registered in either group. Accuracy
error rate decreased both in NICU
(54.7vs 23% P < 0.001 Chi2) and
HPS (38.3 vs 14.6% P < 0.010 Chi2).
OR 0.38 95% CI (0.28–0.53)⁎
Niemann et al., 2014 Germany Prospective PCCU (nurses) 1 PCCU Unit (142 3 step intervention (training course, Drug error prevalence decreased
intervention participants) information handout, and a 76-page from 83% (555 errors/668
study reference book) processes) to 63% (554/883;
p < 0.001) after the intervention,
OR 0.76 95% CI (0.65–0.88)⁎.Number
of affected patients remained
unchanged (95% vs. 89%,
p = 0.370). PO drugs (1.33 errors/
process) were more error-prone
than IV drugs (0.64), despite being
used less frequently (27% vs. 73% of
all processes, p < 0.001). The
interventions decreased the
prevalence to 0.77 errors/process
(p < 0.001) in PO and to 0.52 in IV
drugs (p = 0.025). O
Bertsche et al., 2010 Germany Prospective, Paediatric 17 nurses and 30 educational program including; Post-intervention errors reduced
two-period neurology ward parents implementation instructions for from 261/646 tasks (40.4%) to
cohort (doctors, nurses appropriate drug administration, 36/453 (7.9%, p < 0.001) in nurses
intervention and parents) and drug information services and from 28/29 (96.6%) to 2/36
(5.6%, p < 0.001) in parents. OR
0.11, 955 CI (0.07–0.16)⁎
Otero et al., 2008 Argentina Cross-sectional Paediatrics hospital 4496 medications educational program including; a) Prevalence of medication error rate
(physicians, nurses proposed modifications on reduced from 11.4%
and pharmacists) medication prescription process (2) pre-intervention to 7.3%
active interaction with pharmacists post-intervention (ARR (−4.1%),
during rounds, and (3) 95% CI (−2.3) - (−5.8)), OR (0.61,
implementation of a 10 steps check 95% CI 0.50–0.75).
list on medication error reduction. Prescription error rate decreased
from 11.4% to 7.3%, ARR ((−8.1%),
95% CI (−4.6) - (−11.6)), OR (0.48,
95% CI, 0.36–0.65).
Administration error rate decreased
from 17.3% to 9.2% ARR ((−2.5%),
95% CI (−0.5) - (−4.5)), OR (0.68,
95% CI, 0.51–0.91).
Guérin et al., 2015 Canada Retrospective Paediatric hospital All staff in a 500 bed implementing smart infusion pumps A total of 2911 (accidents and
pre–post (nurses, doctors mother-child incidents) events related to
and pharmacists) hospital medications, devices, and
equipment were self-reported by
clinical staff in the pre-phase (Y0),
3523 in the post-phase (Y1), and
2788 in the post-phase (Y2). The
total AIIV increased from 1432 in Y0
to 1834 in Y1 and further decreased
to 1389. Drug related events OR post
phase (Y2) 0.81, 95% CI (0.67–1.0)⁎
Raja Lope et al., 2009 Malaysia Prospective NICU (nurses) 50 nurses observed Education programme MAEs reduced from 31% (59/88) pre
pre and post during phase 1 intervention to 15.4% (26/169)
intervention 51 nurses observed post-intervention (P < 0.001) OR
study during phase 2 0.40, 95% CI (0.24–0.67)⁎
Stewart et al., 2010 Northern Prospective Fourth year 193 education programme (teaching and After intervention, students
Ireland cohort medical students workshop training) reported an increase in their
and third year knowledge and awareness on
nursing students paediatric medication safety, pre
and post mean scores 53.9 vs 69.8

4
T.C. Marufu, R. Bower, E. Hendron et al. Journal of Pediatric Nursing xxx (xxxx) xxx

Table 1 (continued)

Author and year Country Type of study Participants Sample size (N) Interventions Results

(mean difference 15.9, 95% CI

10.4–21.4 P < 0.001), shared
learning pre and post mean scores
67.9 vs 76.6 (mean difference 8.9,
95% CI 4.3–13.1 P < 0.001)
Chedoe et al., 2012 Netherlands Prospective NICU nurses 311/718 (43%) Multifaceted educational The incidence of errors decreased
cohort doses observed programme from 49% to 31%. Pre-intervention
pre-intervention, rates 0.3% severe errors, 26%
284/1221 (23%) moderate and 23% minor errors.
doses observed Post-intervention rates 0% severe
post-intervention errors, 23% moderate and 8% minor
errors. OR 0.49 (0.29–0.84) for
period (p = 0.032), route of
administration (p = 0.001)
Simpson et al., 2004 Scotland, Prospective NICU(doctors and 105 drug errors Educational program including; Post-interventions, monthly
UK cohort nurse) implementation of clinical medication errors fell from a mean
pharmacy, and drug information (SD) of 24.1 (1.7) per 1000 neonatal
services. activity days to 5.1 (3.6) per
1000 days (P < 0.001) in the
following three months. The
subsequent change over of junior
medical staff was associated with a
significant increase in medication
errors to 12.2 (3.6) per 1000
neonatal activity days (p = 0.037).
Abuelsoud, 2019 Saudi Prospective Paediatric specialty 900 medical files educational program including; MAE rates during prescribing,
Arabia cohort (physicians, nurses reviewed to detect implementation of clinical administration, and monitoring
and pharmacists) drug related pharmacy, and drug information stages decreased from 47, 60, and
problems services 56% to 10, 10 and 15% respectively
within 9 months after intervention.
OR 0.15, 95% ci (0.13–0.17)⁎,
prescription error OR 0.13, 95% CI
(0.08–0.16)⁎, administration error
OR 0.12, 95% (0.09–0.15)⁎.

Abbreviations: PCCU, Paediatric Critical Care Unit, ARR, absolute rate ratio, OR, odds ratio, RR, rate ratio, MAEs, medical administration errors.
⁎ Highlihgt OR calculated from baseline data presented in the respective study.

reference books), involvement of clinical pharmacists, double checking,
smart pumps, barriers to reduce interruptions during drug calculation
and preparation and improvement strategies (checklists, policy and
process change).
Some of the studies implemented single interventions only while
others used a bundle of interventions. Education program interventions
were the most common, observed in thirteen studies. Five studies im-
plemented the specific education programs only (Campino et al.,
2009; Campino et al., 2016; I. Chedoe et al., 2012; Raja Lope et al.,
2009; Stewart et al., 2010), while the other eight studies included
other interventions with education program (Abuelsoud, 2019;
Bertsche et al., 2010; Hebbar et al., 2018; Kanjia et al., 2019;
McSweeney et al., 2019; Niemann et al., 2014; Otero et al., 2008;
Simpson et al., 2004).
The following three intervention; education, drug information ser-
vices and clinical pharmacy involvement programmes are closely asso-
ciated and in some context interdependent, depending on the delivery
strategy. Education intervention sessions were delivered periodically
through lectures, workshops with scenarios, drug administration simu-
lations and specific practical training for staff involved in intravenous
administration. Staff competency was assessed via a series of practical
exercises including dose calculations. Staff education materials or med-
icines information were printed and made available (training course in-
formation, handouts, and information providing clear medication
administration instruction and good administration practices). Simula-
tions and workshop practicals consisted of high reliability principles
consistent with error prevention such as closed loop communication,
team member check in and STAR (Stop, Think, Act, Review) (Hebbar
et al., 2018), and double checking. An example of a simulation exercise
is as follows; the staff nurse reads the drug chart, identifies the correct
drug from storage, correct dose calculation counter checked by a col-
league, prepares medication aseptically, labels prepared drug, check
patient's identification, check drug prescription/medication label
again, administer medication to the patient ensuring the right time,
rate, route, colleague counterchecks administration (Raja Lope et al.,
2009). Sessions were delivered by various staff groups with additional
support from pharmacy staff until competency is achieved.
Clinical pharmacy service interventions were not limited to educa-
tion only. Clinical pharmacist led daily bedside medications reviews fo-
cusing on issues relating to prescribing, documentation and
administration were implemented (Simpson et al., 2004). Senior phar-
macists were included in the daily medical team ward rounds with spe-
cific intravenous medications mixtures prepared in pharmacy
(Abuelsoud, 2019).
The use of smart pumps were evaluated in three studies (Guérin
et al., 2015; Manrique-Rodríguez et al., 2013; Subramanyam et al.,
2016), computer assisted drug calculations, barriers to reduce interrup-
tions during drug calculations and double checking before intravenous
administration were used in one study each (Colligan et al., 2012;
Subramanyam et al., 2016; Yamamoto & Kanemori, 2010).
Smart infusion pump interventions involved provision of training for
all nursing staff in programing medicine administration pumps. These
smart pumps have safety software with built in drug libraries and
drug infusion guardrails or limits to reduce probability of error occur-
rence. Training covered the expected and appropriate operation of the
pumps as well as the expected change in practice. The process change
involved use of itemised checklist, for compliance to ensure all steps
of safe drug administration were followed to reduce drug errors. Pocket

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T.C. Marufu, R. Bower, E. Hendron et al. Journal of Pediatric Nursing xxx (xxxx) xxx

Records idenfied through

database searching.
Idenficaon
(512)

Records screened Records excluded

Screening

(n = 442) (n = 423)

Full-text arcles excluded,

Eligibility

Full-text arcles assessed with reasons

for eligibility 1 Full text requested from
(n =19) authors but not received
Included

Studies included:

(n = 18)

Fig. 1. Flow diagram of included and excluded studies.

cards with steps to prevent errors in the administration of medications Ten studies were included in a meta-analysis of interventions to re-
were given to all clinicians (Otero et al., 2008). duce MAEs (Fig. 2). Three studies (Bertsche et al., 2010; Chedoe et al.,
Meta-analysis of interventions to reduce MAEs. 2012; Otero et al., 2008) had their results presented in odds ratio (OR)

Fig. 2. Meta-analysis of interventions to reduce MAEs.

6
T.C. Marufu, R. Bower, E. Hendron et al.
and for the other seven studies, we used pre and post intervention data
provided to calculate OR. Calculated OR for individual studies are pre-
sented in Table 1. The meta-analysis showed a pooled OR 0.36 (95%
Confidence Interval (CI) 0.21–0.63) P = 0.0003) for test of overall effect.
The analysis demonstrates an associated 64% reduction in medicines ad-
ministration errors post intervention. However a high heterogeneity
(I2 = 98%) was observed demonstrating high variation in study out-
comes between included studies. No subgroup group analysis was per-
formed.
Publication bias
Publication bias was visually assessed using funnel plot developed
using Rev. Man5. The plot was asymmetric indicating a possible risk of
publication bias (Fig. 3 Funnel Plot).
Narrative synthesis
Studies not included in the meta-analysis presented their results in
various forms. Four studies (Hebbar et al., 2018; Manrique-Rodríguez
et al., 2013; McSweeney et al., 2019; Simpson et al., 2004) showed a sig-
nificant reduction in MAEs after interventions. Hebbar et al. (2018) re-
ported a decrease in MAE events from 2.5 to 1.4 per month (risk ratio
(RR) 1.78, 95% CI 1.03–3.1 p = 0.02) during the 20 months rollout of a
targeted simulation training to reduce serious medication events. A fur-
ther reduction of monthly error events to 0.86 at 7 months post inter-
vention was reported demonstrating a 63% decrease in MAEs from
baseline period (RR = 2.9, 95% CI = 1.2–8.5, P = 0.014).
In a study by Manrique-Rodríguez et al. (2013), the intervention
(use of smart infusion pumps) intercepted 92 user programming errors
rated as potential harm to the patient. The authors concluded that using
smart infusion pump programming such as pump drug library, defined
hard limits for infusion rates is associated with a 49% potential reduction
or intercepting drug errors of moderate, serious or catastrophically se-
vere cases. One study (Colligan et al., 2012) implemented the barriers
to reduce interruptions during drug calculation and preparation. They
measured mean interruption rate per minute. They reported a signifi-
cant mean interruption reduction from 1.4 pre-intervention to 0.27
post-intervention, p < 0.01.
For studies that involved process and policy changes (Kanjia et al.,
2019; Subramanyam et al., 2016) uptake of process change as part of
the interventions increased to 97% and from 0 to 90% respectively. The
Northern Ireland study (Stewart et al., 2010) targeted fourth year med-
ical students and third year nursing students to deliver an education
programme through teaching and workshop training to raise awareness
on paediatric medication safety. After the intervention, students
Fig. 3. Funnel Plot.
7
Journal of Pediatric Nursing xxx (xxxx) xxx
reported an increase in their knowledge and awareness of paediatric
medication safety; with pre and post mean scores of 53.9 vs 69.8
(mean difference 15.9, 95% CI 10.4–21.4 p < 0.001), and shared learning
experience on medication safety pre and post mean scores 67.9 vs 76.6
(mean difference 8.9, 95% CI 4.3–13.1 p < 0.001).
Discussion
The current review provides an update on intervention strategies to
reduce medication administration errors in paediatric and neonates.
Causes of medication errors during administration are multifactorial
sometimes requiring multi-faceted interventions to address the root
cause. This is reflected in our findings. The seven interventions identi-
fied included; education projects, medication information services, clin-
ical pharmacist involvement, double checking, barriers to reduce
interruptions during drug calculation and preparation, implementation
of smart pumps (new technology) and improvement strategies. Most
studies performed bundle as opposite to single interventions. Similarly
to what has been observed in previous reviews, all included studies
were single arm, pre and post design without a comparative, concurrent
control group (Bannan & Tully, 2016; Nguyen et al., 2017). All interven-
tions demonstrated a reduction in medication errors.
In comparison to other similar recent reviews (Bannan & Tully,
2016; Nguyen et al., 2017; Rinke et al., 2014; Santesteban et al., 2015),
in this review we performed a meta-analysis in ten studies with pooled
size of effect OR showing a 64% associated reduction in MAEs after inter-
vention. Methodological and study results presentation heterogeneity
was observed in included studies. This variation precluded meta-
analysis for some of studies.
One of the predominant reason children are at greater risk from
medication errors is the nature of drug dosages that are calculated
based on the child's weight or body surface (Wong et al., 2009). How-
ever, weight can change during hospitalisation period and recalculation
of drug dosages becomes a necessity particularly in neonates. As such, in
addressing this key element, all education program interventions ob-
served included elements of dose calculations, with some offering nurs-
ing staff further support until competency is achieved. Accurate
medicine administration calculations is an essential part of patient
safety and nurses competency such that it has become part of the curric-
ulum with nursing schools dedicating time and effort to teach their stu-
dents how to calculate drug doses and subsequently test them for these
skills (Rowe et al., 1998).
It has previously been hypothesised that a bundle interventional ap-
proach, that is using more than one intervention with more than one
function has an additive advantage on reducing medication errors
(Bannan & Tully, 2016). This is considerably plausible as individual in-
terventions often target different aspects of the medication manage-
ment and administration process demonstrating that a combination of
interventions is most likely required to achieve a significant reduction
in MAEs (Nguyen et al., 2017). Therefore investigating and categorising
different types of medication errors in accordance to the local context is
a necessary step as part of designing and before implementing any pro-
posed intervention.
Several studies (Campino et al., 2009; Campino et al., 2016; Raja
Lope et al., 2009) have demonstrated that to reduce medication errors,
a change in the patient safety culture is of necessity coupled with spe-
cific training to promote effective sustainable change. To this effect,
the role of structured educational intervention component as part of a
MAE preventive strategy is worth noting. Thirteen studies (72%) out of
18 included studies in this review included an education component.
Two previous reviews on a similar topic reported 94% (Bannan &
Tully, 2016), and 30% (Nguyen et al., 2017) of included studies having
either a staff or medication education component as part of the inter-
vention strategy. Primarily the education aspects of the interventions
are focused on increasing and addressing medication knowledge and
understanding. This is often delivered in form of simulations or lectures
T.C. Marufu, R. Bower, E. Hendron et al.
addressing potential error prone points in the medication administra-
tion process (Campino et al., 2009; Campino et al., 2016). The use of
simulation techniques during teaching sessions has been reported to
have a substantial effect in medication administration error reduction
(Ford et al., 2010). A systematic review of 15 studies on educational in-
terventions alone to improve prescribing quality provided no definitive
conclusion (Ross & Loke, 2009), which might suggest that education
programmes are impactful only as part of bundle as opposed to stand
alone intervention. However studies included in this review using edu-
cation interventions alone to address medication errors during adminis-
tration (Campino et al., 2009; Campino et al., 2016; Raja Lope et al.,
2009; Stewart et al., 2010) demonstrated reduction in drug errors post
intervention, although one of the studies concluded that the reduction
was insufficient to achieve an adequate level of medication safety
(Chedoe et al., 2012).
In this review, another commonly observed intervention used as
part of bundle is the collaboration of clinical pharmacists on medicine
activities with nurses. Involvement of clinical pharmacists has shown
to prevent 58% of medication errors and 72% of potentially high risk er-
rors (Fortescue et al., 2003). The presence of clinical pharmacists may
help nurses to make informed clinical decisions at any point during
drug administration process. Pharmacokinetic monitoring, up-to-date
information on reconstitution and dilution of drugs, compatibility of in-
travenous medication and collaboration with other healthcare profes-
sionals to optimise therapeutic plans are roles a clinical pharmacist
can undertake (Campino et al., 2009; Prot-Labarthe et al., 2013).
Study limitations.
There are various types of medicine errors; prescribing, preparation
and dispensing, monitoring and administration errors and these errors
often influence the outcome of each other. Also the type of errors
might be influenced more by one healthcare professional group, for ex-
ample medication prescription is mainly the medical team's responsi-
bility while drug administration is often done by the nursing staff. This
review focused on drug administration error reduction interventions
only, which might not give a true picture of the challenges and complex-
ities to be considered when implementing such interventions. Some
studies that predominantly looked at other drug error types with mini-
mum emphasis on medicines administration errors could have been
missed. However we performed a comprehensive search strategy to en-
sure inclusion of all possible studies.
There are frameworks such as the Cochrane Effective Practice and
Organisation Care Group (EPOC) (2015) taxonomy of intervention and
the Behaviour Change Wheel (BCW) approach (Michie et al., 2011),
which have categorised interventions to improve the quality of care or
reduce errors (Maaskant et al., 2015; Smith et al., 2016). The EPOC tax-
onomy stratifies interventions into four groups; professional,
organisational, financial and regulatory depending on the target. On
the other hand, the BCW classify interventions based on their function;
environmental restructuring, education, persuasion, incentivisation, co-
ercion, training, restriction, modelling and enablement. While such
frameworks have been used in previous reviews (Bannan & Tully,
2016; Nguyen et al., 2017) in this review we grouped identified inter-
ventions from included studies together according to their similarity
for clarity to the readers.
Implications for practice
Findings from this review broadly highlight the following three as-
pects for consideration by practicing nurses and their respective health
care organisation; a) medication errors are multifaceted and the causes
of errors need to be identified prior to implementation of appropriate
interventions, b) medication safety education is an integral element of
interventions in a bid to reduce administration errors and
c) interdisciplinary collaboration in the medication process contributes
to the reduction of medication administration errors. In view of the
outlined considerations, the following, bundle interventions could be
8
Journal of Pediatric Nursing xxx (xxxx) xxx
considered most beneficial to practicing nurses. Education interventions
(which include but not limited to lectures, workshops, simulations and
practical training) and provision of relevant drug information services
remain predominantly fundamental in reducing medicines administra-
tion errors. Regular education sessions and updates on medicines ad-
ministration could also be used as part of nursing staff continuous
professional development (CPD) to enhance evidence based practice.
The multidisciplinary nature of healthcare provision requires the in-
volvement of clinical pharmacy services to ensure delivery of safe med-
ications care. This affords practising nurses easy access to pharmacists
during working hours and out of hours if further discussion is required
(Abuelsoud, 2019). The use of smart pumps with medicines library and
guard rails are now prevalent and part of standard care in most clinical
areas with provision of equipment training a prerequisite.
Conclusion
Administration of medicines to children via any route can sometime
be a complex process requiring special attention and multifaceted inter-
ventions to reduce and or avoid potential errors. There is no ‘one size fit
all’ solution in reducing medication administration errors. Identifying
causes of errors within the local context and understanding conditions
and mechanisms that exacerbate such practice performances is neces-
sary in designing or choosing potential effective interventions from
the list outlined in this review. Continuous monitoring and evaluation
of interventions used in clinical practice is paramount for measuring ef-
fectiveness and ensuring patient safety.
Funding
None.
Availability of data and material
N/A
Code availability
N/A
Authors' contributions
Marufu and Manning conceptualized and designed the study.
Hendron performed the search strategy, Marufu, Bower and Manning
performed data extraction. All the authors were involved in data analy-
sis and have contributed to the drafting, critical review and revision of
the manuscript. All authors have approved the final manuscript.
Conflicts of interest
Dr. Joseph C. Manning is a current recipient of an NIHR HEE funded
ICA Clinical Lectureship [ICA-CL-2018-04-ST2-009]. The views
expressed in this article are those of the authors and not necessarily
those of the NIHR or Department of Health and Social Care, UK.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.pedn.2021.08.024.
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