eTable. Measures to improve the quality of drug prescriptions for children and evidence of their effects.
| Level of evidence according to EBM*1, author, year | Study design, target criterion, intervention | Methods, groups | Effect |
| Source of error: age group–specific knowledge (indication, contraindications, dosing recommendations) | |||
| III, Mullett 2001 (7) | Prospective cohort study, comparison of error rate in antibiotics prescriptions, introduction of electronic database for treatment decisions | 1758 patients admitted over one year, pediatric intensive care unit1) Before 2) After introduction of database | Risk of inappropriately high or low doses (of clinical relevance)1) 16 per 100 patient days 2) 11 per 100 patient days (p <0.0001) |
| IV, Sard 2008 (8) | Retrospective cohort study, comparison of error rate in drug prescriptions, introduction of table summarizing pediatric drug therapy | 724 prescriptions, pediatric emergency department1) Before 2) After introduction of dosing table | Comparison of error rate1) 18% 2) 2% (RR: 0.10, CI: 0.02 to 0.42) |
| Source of error: determining weight | |||
| III, Krieser 2007 (9) | Prospective observational study, comparison of estimated/measured weight, various methods of estimating | 410 children aged 0 to 10 years, pediatric emergency department1) Estimated by parents 2) Length-related estimates 3) Three age-related formulae | Comparison of estimated & measured weight1) 78% of cases within 10% 2) 61% of cases within 10% 3) 34% to 42% of cases within 10% |
| Source of error: dose calculation | |||
| II, Shah 2003 (10) | Prospective, randomized, controlled crossover study, comparison of deviation of drug doses from recommended dose, use of a pediatric emergency ruler | Simulated resuscitation on pediatric manikins, each 4 events by 28 physicians1) Not using 2) Using pediatric emergency ruler | Deviation of doses from recommended dose, %1) 36.3% (CI: 29.3 to 51.2%) 2) 7.6% (CI: 4.5 to 9.1%) |
| III, Cordero 2004 (11) | Prospective cohort study, comparison of error rate in prescriptions of gentamicin, introduction of electronic calculation aid | 211 preterm infants, neonatal intensive care unit1) Before 2) After introduction of electronic calculation aid | Comparison of error rate1) 13% 2) 0% |
| III, Kirk 2005 (12) | Prospective cohort study, comparison of error rate in drug prescriptions, introduction of electronic calculation aid (dose calculated by computer) | 4274 drug prescriptions, pediatric hospital1) Before 2) After introduction of electronic calculation aid | Comparison of error rate1) 28.2% 2) 12.6% (RR: 0.44; p <0.001) |
| II, Bernius 2008 (13) | Randomized controlled trial, correct prescriptions in a prescription form, table used for reference | Pediatric prescription form, 523 emergency physicians1) Using 2) Not using table for reference | Correct pediatric prescription forms1) 65% 2) 94% |
| III, Wong 2009 (14) | Prospective observational study, correct prescriptions of gentamicin in a prescription form, using a handbook or dosing table | Four prescriptions (2 neonatal, 2 pediatric) in a test, 51 nurses, pediatric hospital1) Using handbook 2) Using dosing table | Correct answers, pediatric prescription1) 80% 2) 100% Correct answers, neonatal prescription 1) 35% 2) 55% (only errors of prescription frequency) |
| Source of error: issuing prescription | |||
| II, Kozer 2005 (15) | Randomized controlled trial, comparison of error rates in a structured prescription form | 787 drug prescriptions, pediatric emergency department1) Written on blank paper 2) Written on form | Rate of medication errors1) 16.6% 2) 9.8% (OR: 0.55; CI: 0.21 to 0.77) |
| IV, Larose 2008 (16) | Retrospective cohort study, comparison of error rates in a structured prescription form | 719 drug prescriptions, pediatric emergency department1) Written on blank paper 2) Written on form | Rate of medication errors1) 15% 2) 6% (∆9%; CI: 5 to 13) |
| IV, Broussard 2009 (17) | Retrospective observational study, comparison of error rates in a structured sedative prescription form | 84 prescription forms, pediatric hospital1) Written in patients’ records 2) Written on form | Rate of medication errors1) 25% 2) 9% (p <0.001) |
| Comprehensive or multiple measures | |||
| III, Morriss 2009 (18) | Prospective cohort study, risk rate of medication errors, barcodes on syringes & electronic control system | 92 398 prescriptions, neonatal intensive care unitAfter introduction of barcodes & control system | Relative risk of medication errors RR: 0.53 (CI: 0.29 to 0.91; p = 0.04) |
| III, Davey 2007 (19) | Prospective cohort study, comparison of prescription errors, training in pediatric prescriptions | Total of 515 prescriptions, pediatric hospital1) Before 2) After training | Rate of prescription errors1) 31% 2) 17% (p <0.001) |
| II, Gordon 2011 (20) | Randomized controlled trial, comparison of results of a test on pediatric prescriptions, e-learning on pediatric prescriptions | Written test, 86 doctors did not receive training, 76 did1) Before e-learning 2) One month after e-learning 3) Three months after e-learning | Correct results in written tests1) 67% vs. 67% (p = 0.56) 2) 79% vs. 63%) (p <0.0001) 3) 79% vs. 63% (p <0.0001) |
| III, Taylor 2008 (21) | Prospective observational study, comparison of deviations from recommended doses, introduction of electronic prescription system | Total of 526 prescriptions, neonatal intensive care unit1) Before 2) After introduction of electronic prescription system | Deviation from recommended doses1) 20% of prescriptions 2) 11% of prescriptions (RR: 0.53) |
| III, Walsh 2008 (22) | Prospective observational study, comparison of error rate, introduction of electronic prescription system (inspection of prescription had already been implemented) | 12 672 prescriptions, neonatal & pediatric intensive care units, normal ward1) Before 2) After introduction of electronic prescription system | Dangerous prescription errors1) 22 per 1000 patient days 2) 7% reduction in harm caused by prescription errors 1) 7 per 1000 patient days 2) No reduction |
| III, King 2003 (23) | Prospective observational study, comparison of prescription errors & potentially dangerous errors, introduction of electronic prescription system (without pediatric drug database) | Rate of prescription errors & potentially dangerous errors 1) Units with 2) Units without electronic prescription system | Comparison of rate of prescription errors2) RR: 0.6 (CI: 0.48 to 0.74), i.e. an improvement Comparison of rate of dangerous errors 2) RR: 1.3 (CI: 0.47 to 3.52), i.e. a deterioration |
| III, Campino 2009 (24) | Prospective cohort study, rate of dosing errors, training | Total of 5694 prescriptions, neonatal intensive care unit1) Before 2) After introduction of training | Rate of prescription errors1) 5% 2) 0.2% (p <0.001) |
| III, Potts 2004 (25) | Prospective cohort study, comparison of rate of prescription errors, introduction of electronic prescription system with incorporated pediatric drug database | Total of 13 828 prescriptions, pediatric intensive care unit 1) Before 2) After introduction of prescription system | Comparison of rate of prescription errors1) 30.1 per 100 prescriptions 2) 0.2 per 100 prescriptions (p <0.001) comparison of rate of dangerous errors 1) 2.2 per 100 prescriptions 2) 1.3 per 100 prescriptions (p <0.001) |
| III, Kazemi 2011 (26) | Prospective cohort study, comparison of rate of dangerous prescription errors, introduction of electronic prescription system with incorporated database | Total of 3206 prescriptions, neonatal unit1) Before 2) After introduction of electronic prescription system 3) With the addition of incorporated database | Rate of dangerous prescription errors1) 2.5% 2) 2.4% 3) 0.8% (p <0.005) |
| III, Kidd 2010 (27) | Prospective cohort study, comparison of results of a test on pediatric prescriptions, introduction of training, specialist information & pocket calculator available | 32 vs. 30 young physicians, pediatric hospital 1) Before 2) After training, handbook, pocket calculator | Correct answers1) 58% of answers correct 2) 93% (∆ 36%; CI: 24 to 47) |
| IV, Kadmon 2009 (28) | Retrospective cohort study, rate of prescription errors & potentially dangerous errors, introduction of electronic prescription system/incorporation of database into such system/prescriptions issued by physicians only (previously also issued by nurses) | 3750 prescriptions (antibiotics & anticonvulsives), pediatric hospital1) Before 2) After introduction of electronic prescription system 3) Incorporation of database 4) Prescriptions can only be issued by physicians | Prescription errors/potentially dangerous errors1) 5.5%/2.5% 2) 5.3%/2.4% 3) 3.8% (p <0.05)/0.8% (p <0.001) 4) 0.7% (p <0.005)/0.7% (p <0.001) |
| III, Campino 2008 (29) | Prospective, controlled cohort study, rate of dosing errors, introduction of inspection of prescriptions by hospital pharmacists | 4304 prescriptions, neonatal intensive care unit1) Before 2) After introduction of inspection | Rate of dosing errors1) 14% 2) 5% (p <0.001) |
| IV, Costello 2007 (30) | Controlled cohort study (retrospective control group, prospective intervention groups), rate of medication errors causing potential or actual harm, introduction of inspection of prescriptions by hospital pharmacists/CIRS/training | Pediatric intensive care unit1) Before (2 months observation period) 2) After introduction of inspection (4 months observation period) 3) Inspection, training, CIRS (4 months observation period) | Rate of medication errors causing potential of actual harm1) 46% 2) 8% 3) 0% |
| III, Larsen 2005 (31) | Prospective cohort study, rate of reported medication errors & tenfold errors in continuous intravenous administration, introduction of standard concentrations/computer-generated syringe barcodes/smart syringe pumps | 12 399 prescriptions, pediatric hospital1) Before 2) After interventions | Medication errors per 1000 prescriptions1) 3.1 2) 0.8 (∆ 2.3; CI: 1.1 to 3.4; p <0.001) tenfold errors per 1000 prescriptions 1) 0.41 2) 0.08 |
| III, Stewart 2010 (32) | Prospective comparative study, results of a test on pediatric prescriptions, seminars on pediatric drug therapy, communication, & teamwork | Comparison of test results of 68 participants1) Before 2) After seminar participation | Improved knowledge of - Awareness of drug safety - Causes of drug errors - Communication & teamwork |
| IV, Otero 2008 (4) | Retrospective comparative study, rate of medication errors, development of training program with multiple components (standardized prescriptions, supervision, interdisciplinary discussions, pharmacist ward round, checklists, CIRS, database) | 1734 prescriptions, pediatric units 1) Before 2) After multiple interventions | Medication errors per 1000 prescriptions1) 11% 2) 7% (OR: 0.61; CI: 0.5 to 0.75) |
| III, Leonard 2006 (33) | Prospective cohort study, rate of medication errors, e-learning/inspection of prescriptions with feedback/monthly discussions | 8718 prescriptions, pediatric hospital1) Before 2) After multiple interventions | Rate of potentially dangerous prescription errors1) 78 per 100 prescriptions 2) 40 per 100 prescriptions (p = 0.01) |
| III, Kaji 2006 (34) | Prospective observational study, comparison of epinephrine dosing accuracy within 20% of the recommended dose, introduction of a pediatric emergency ruler (the Broselow tape) | 141 children, prehospital resuscitations1) Not using 2) Using emergency ruler | Accurate dose recommended/administered to within 20%1) 34% 2) 67% |
| III, Ligi 2010 (35) | Prospective cohort study, rate of tenfold medication errors, introduction of a CIRS system & error prevention strategies based on it | 1033 patients, neonatal intensive care unit1) Before 2) After introduction of CIRS plus derived strategies | Rate of tenfold dosing errors1) 2.3 per 100 patients 2) 0.6 per 100 patients (p = 0.02) |
| IV, Koren 2002 (36) | Retrospective cohort study, rate of medication errors, computer-based prescription system/sorting of available drugs/training | 1.8 million drug administrations annually, 2-year observation period, pediatric hospital1) Before 2) After intervention | Rate of medication errors made by physicians1) 0.04% 2) 0.02% (p <0.001) |
| IV, Sharek 2008 (37) | Prospective observational study with retrospective control group, rate of potentially dangerous medication errors, participation in risk analysis & multifactor process optimization | Anesthesiology departments in 14 pediatric hospitals Before/after intervention | Frequency of drug errors 67% reduction (p <0.001) |
*1Level of evidence according to the Centre for Evidence-Based Medicine, 2011 (e37): I: Meta-analysis of randomized controlled trials; II: Randomized controlled trial; III: High-quality (prospective) controlled trial (nonrandomized); IV: Case series, case-control study, or historically controlled trial; V: Case reports, expert opinions. CIRS: Critical Incident Reporting System; CI: Confidence interval; RR, Relative risk; OR: Odds ratio; ∆: Difference