Awareness, Practices, and Contributing Factors.7

Original Article
Awareness, Practices, and Contributing Factors toward Medication

Errors in Children among Pediatric Nurses
Sonali Singh, S. Malar Kodi1, Rupinder Deol1
Department of Pediatrics, All Context: Medication errors are a global issue that poses a significant threat to
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Abstract
India Institute of Medical
Sciences, 1Department
patient safety and results in serious harm. Inconsistencies in drug formulations
of Pediatrics, College of make children more susceptible to medication errors. Nurses have the
Nursing, All India Institute of primary responsibility of preventing medication errors in children. Aim: The
Medical Sciences, Rishikesh, aim of this study was to assess the awareness, practices, and contributing
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 04/03/2024
Uttarakhand, India factors among pediatric nurses at a selected tertiary care hospital, Rishikesh.
Setting and Design: This was a cross‑sectional study conducted at a tertiary
care hospital in Rishikesh (Uttarakhand), India. Methods: One hundred and
twenty nurses working in pediatric care units at a tertiary care hospital in
Rishikesh were involved in the study. The participants were chosen using the
total enumerative sampling technique in accordance with the inclusion criteria.
A self‑structured questionnaire and Likert scale was used to collect the data.
Statistical Analysis: The collected data were analyzed using frequency, mean and
standard deviation, Pearson correlation, Fisher’s exact test, and Chi‑square test
using the SPSS software version 26.0. Results: Majority (70%) of the pediatric
nurses were moderately aware and most of them (80%) were practicing safely
toward medication errors in children. The most common reason for medication
errors in children was a lack of familiarity with look‑alike and sound‑alike drugs.
Conclusion: The study findings revealed that awareness and practices toward
reporting of medication errors in children among the pediatric nurses needs to
be improved by establishing the guidelines and organizing in‑service education
Received: 09‑Sep‑2023
programs, the incidence of medication errors in children can be reduced.
Revised: 12‑Dec‑2023
Accepted: 11‑Jan‑2024
Keywords: Awareness, contributing factors, medication errors and pediatric
Published: 27-Mar-2024 nurses, practices
Introduction errors were reported, with an error rate of 1 in every

9.5 patients out of 2600 prescriptions.[3,4]
M edication errors are a global issue and the
third leading cause of death after heart disease
and cancer, threatening patients’ safety in hospitals.
The term "medication error” refers to the errors
occurred during administration, monitoring, storage and
Globally, there were around 1.3 million reported cases documentation of drugs leading to injury to patients.
of medication errors. In India, there are approximately Medication errors can be committed by various staff
5.2 million medication errors that occur every members including physicians, pharmacists, nurses,
year.[1] The state government of Uttarakhand reported students, pharmaceutical manufacturers, and patients
approximately 26% of medication errors.[2] Children regardless of their level of experience.[5]
are more prone to medication errors primarily dosage
errors and prescribing errors due to the variation in Address for correspondence: Dr. S. Malar Kodi,
College of Nursing, All India Institute of Medical Sciences,
their height, weight, age, and lack of pediatric specific Rishikesh, Uttarakhand, India.
formulations. The pediatric population had a higher rate E‑mail: malar.nur@aiimsrishikesh.edu.in
of medication errors than the adult population and 273
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How to cite this article: Singh S, Kodi SM, Deol R. Awareness, practices,
DOI: 10.4103/ajprhc.ajprhc_114_23 and contributing factors toward medication errors in children among
pediatric nurses. Asian J Pharm Res Health Care 2024;16:37-44.
© 2024 Asian Journal of Pharmaceutical Research and Health Care | Published by Wolters Kluwer - Medknow 37
Singh, et al.: Awareness, practices, and contributing factors toward medication errors in children among pediatric nurses
The National Patient Safety Agency reported Sampling size and sampling technique
that nurses are responsible for the majority of One hundred and twenty nurses were selected using the
medication errors (59.3%) that occur during the drug enumerative sampling technique who had fulfilled the
administration.[6] The most common mistakes were inclusion criteria.
those associated with administering medication at the Pediatric nurses who were working in pediatric units
wrong time, to the wrong patient, using the wrong were included and pediatric nurses those were on long
dose, drug, or route, and failing to administer the leave and were not directly involved in medication
medication at all. administration during the period of data collection such
as ward administrators, assistant nursing superintendent,
There are several factors contributing to medication
and deputy nursing superintendent were excluded.
errors such as lack of knowledge/experience among
health‑care professionals, poor communication, memory Tools used for data collection
lapses, improper labeling and storage of look‑alike and Awareness was assessed using a self‑structured
sound‑alike (LASA) drugs, overburden, poor physical questionnaire having 20 items with four domains. The
environment, tablet splitting, use of abbreviations in level of awareness was categories as highly aware,
prescriptions, inconsistencies in different formulations of moderately aware, and unaware. The practices of nurses
available drugs available, and language barriers between were assessed using a 5‑point Likert scale having 20
items with five domains (counterchecking, preparation,
health‑care providers and patients.[7] To enhance patient
drug administration, prevention, and reporting
safety and prevent medication errors, it is crucial to
of medication errors). The level of practices was
address these factors.
categorized as safe practices, moderately safe practices,
Medication errors can mainly be prevented through and unsafe practices. Contributing factors were assessed
its timely reporting which is achieved by direct 3‑point Likert scale.
observation, reviewing patients’ charts and incident Validity and reliability of the tool
reports, conducting self-reporting interviews.[8] It is The tool was validated by the seven experts from the
the responsibility of all health-care professionals to field of pediatric nursing, obstetrics and gynecological
take appropriate measures to prevent these medication nursing, and community health nursing. The reliability
errors.[5] Although it is the responsibility of the coefficient of the tool was assessed using split‑half
physician to prescribe the correct dosages to a child, method and the values obtained were (r = 0.7, r = 0.8
it is equally important for nurses to have a thorough and r = 0.7) respectively for the awareness, practices,
understanding of safe dosages, potential side effects, and contributing factors toward medication errors in
and signs of toxicity when administering medication children among pediatric nurses.
to children, as medication administration is one of Ethical approval and informed consent
their primary duties and nurses are the one who cares The participants were informed about all the aspects
for the patient round the clock. Thus, preventing and details of the study. A written informed consent
from the participants for their willingness to participate
Medication errors are a significant and growing problem
in the study was also obtained before enrolling them in
in children, leading to serious consequences such as
the study. The study was conducted after the approval
adverse drug reactions and even death. Thus, it is
by the institutional ethics committee (Approval Letter
important to increase the awareness toward medication Number – AIIMS/ IEC/22/257:27/05/2022).
errors in children to prevent these errors. Hence, the aim
of this study was to assess the awareness, practices, and Data collection procedure
contributing factors toward medication errors in children After obtaining the institutional ethics committee
exclusively among pediatric nurses. clearance, the data were collected from December 1,
2022 to December 31, 2022. The data were collected
Methods using paper and pencil technique through self‑reported
method by the pediatric nurses.
Study design and setting
Statistical analysis
A cross‑sectional study was conducted in selected
pediatric units at AIIMS, Rishikesh. The collected data were analyzed statistically by
using descriptive statistics (mean, frequency, and
Participants standard deviation) and inferential statistics (Pearson
Pediatric nurses. correlation, Fisher’s exact test, and Chi‑square test)
38 Asian Journal of Pharmaceutical Research and Health Care ¦ Volume 16 ¦ Issue 1 ¦ January-March 2024
for assessing the association between the awareness Item wise ranking of awareness toward medication
and practices with selected demographic variables errors
through the Statistical Package for the Social Among all the 20 items, Item number 7 (forgetting to
Sciences version 26, IBM Corp. Released on 2019, in administer the medication to a pediatric patient) ranked
Armonk, New York. first with a mean score and standard deviation of
0.96 ± 0.18 which showed that majority of participants
Results scored maximum marks in this item and were more
Baseline characteristics of pediatric nurses aware about it while Item number 6 (discrepancy
The majority of nurses (60%) were females between between the prescribed drug and the medication order
26 and 30 years with a mean age of 28 years. written in the patient’s medication chart) ranked lowest
Eighty‑seven percentage of them were graduates,
maximum nurses were working in pediatric intensive Table 1: Baseline characteristics of pediatric
care unit (PICU), providing care to 11–20 patients/ nurses (n=120)
Variables Frequency (%)
day in their area, 87% of them had <1 year of
Age group (years), mean±SD 28.27±3.27
experience in pediatric area, and had not any special
21–25 24 (20)
education [Table 1]. 26–30 72 (60)
Level of awareness of pediatric nurses towards 31–35 21 (18)
medication errors >35 3 (02)
The majority of pediatric nurses 70% were moderately Sex
Male 45 (38)
aware toward with a mean score and standard deviation
Female 75 (62)
of 12.03 ± 1.26 and 21% of nurses were highly
Professional qualification
aware with a mean score and standard deviation of
Diploma 13 (11)
16.57 ± 1.52 and only 9% among them were unaware Graduate 104 (87)
with a mean score and standard deviation of 8.54 ± 0.68 Postgraduate 3 (02)
toward medication errors in children [Figure 1]. Clinical area of working
Domain wise analysis of awareness toward Pediatric emergency 23 (20)
medication errors Pediatric medicine 34 (29)
PICU 41 (34)
Out of all four domains, Domain‑1 (types of
Pediatric surgery 22 (17)
medication errors) ranked first with a mean score
Number of patients/day
and standard deviation of 4.80 ± 1.13 which showed 11–20 47 (40)
that the participants scored maximum marks in this 21–30 33 (27)
domain and were more aware about it followed Above 30 40 (33)
by Domain‑3 (prevention) with a mean score and Pediatric experience (years)
standard deviation of 3.33 ± 1.12 which was further No experience 11 (09)
followed by Domain‑2 (risk factors) with a mean <1 104 (87)
score and standard deviation of 2.43 ± 0.93 and 1–5 4 (3.2)
Domain‑4 (reporting) ranked lowest with a mean 5–10 0
score and standard deviation of 2.18 ± 0.76 which >10 1 (0.8)
showed that the participants scored the lowest marks Attended in‑service education
in this domain and were not much aware of this Yes 36 (30)
domain [Figure 2]. No 84 (70)
PICU: Pediatric intensive care unit, SD: Standard deviation
Figure 1: Level of awareness Figure 2: Domain wise analysis of awareness
Asian Journal of Pharmaceutical Research and Health Care ¦ Volume 16 ¦ Issue 1 ¦ January-March 2024 39
with a mean score and standard deviation of 0.25 ± 0.43 Level of practices nurses toward medication errors
which showed that majority participants scored lowest The majority of pediatric nurses 80% were practicing
marks in this item and were not much aware about safely with a mean score and standard deviation of
it [Figure 3]. 88.01 ± 3.74 followed by 20% of them were practicing
Figure 3: Item wise ranking of Awareness Figure 4: Level of practices
Table 2 : Association of level of awareness towards medication errors in children with demographic variables (n=120)
Variables Level of awareness
Highly aware (n=26) Moderately aware (n=83) Unaware (n=11) Test value df P
Age (years)
21–25 9 13 2 6.423a 6 0.327
26–30 15 51 6
31–35 2 16 3
>35 0 3 0
Sex
Male 7 34 4 1.67b 2 0.43
Female 19 49 7
Diploma 1 11 1 2.33a 4 0.63
Graduates 24 70 10
Postgraduates 1 2 0
Clinical area of working
Pediatric emergency 2 17 4 8.91a 6 0.15
Pediatric medicine 9 23 2
Pediatric ICU 10 30 1
Pediatric surgery 5 13 4
Patients/day
11–20 15 29 3 6.03a 4 0.19
21–30 4 24 5
Above 30 7 30 3
Experience in pediatric area (years)
No experience 3 8 0 2.71a 6 0.92
<1 22 71 11
1–5 1 3 0
5–10 0 0 0
>10 0 1 0
Attended any in‑service education on
medication error
Yes 8 25 3 0.04b 2 0.97
No 18 58 8
df=degree of freedom, P significant at<0.05, a=Fisher Exact test b=Chi‑square test
Table 3: Association of level of practices towards medication errors in children among pediatric nurses with
demographic variables (n=120)
Variables Level of practices
Safe (n=95) Moderately safe (n=25) Test value df P
Age (years)
21–25 23 1 6.75a 3 0.06
26–30 52 20
31–35 17 4
>35 3 0
Sex
Male 34 11 0.56b 1 0.45
Female 61 14
Diploma 10 3 3.68a 2 0.14
Graduates 84 20
Postgraduates 1 2
Clinical area of working
Pediatric emergency 9 14 32.81a 3 0.00*
Pediatric medicine 25 9
Pediatric ICU 40 1
Pediatric surgery 21 1
Number of patients/day
11–20 41 6 3.27a 2 0.10
21–30 25 8
Above 30 29 11
Experience in pediatric area (years)
No experience 8 3 1.28a 3 0.89
<1 83 21
1–5 3 1
5–10 0 0
>10 1 0
Attended any in‑service education on medication error
Yes 28 8 0.60b 1 0.80
No 67 17
df=degree of freedom, P significant at <0.05, a=Fisher Exact test b=Chi‑square test
moderately safe with a mean score and standard

deviation of 75.5.57 ± 5.05 toward medication errors
in children. There were no pediatric nurses who were
found to be practicing unsafely [Figure 4].
Domain wise analysis of practices toward
medication errors
Out of all five domains, Domain‑3 (drug administration)
ranked first among all the five domains with a mean Figure 5: Domain wise analysis of practices
score and standard deviation of 41.50 ± 2.36 which
showed that the participants scored maximum marks the participants scored lowest marks in this domain and
in this domain and were more safely practicing on were not safely practicing on this domain [Figure 5].
this domain followed by Domain‑4 (Prevention)
with a mean score and standard deviation of Item wise ranking of practices toward medication
15.50 ± 2.10, Domain‑2 (preparation of drugs) with errors in children
a mean score and standard deviation of 13.40 ± 1.67, Among all 20 items, Item number 14 ranked first with a
Domain‑1 (counterchecking of prescription) with a mean score and standard deviation of 4.95 ± 0.31 which
mean score and standard deviation of 9.08 ± 1.46 showed that majority of participants scored maximum
and Domain‑5 ranked lowest with a mean score and marks in this item and were more safely practicing on it
standard deviation of 5.77 ± 1.41 which showed that while Item number 19 ranked lowest with a mean score
and standard deviation of 2.71 ± 0.74 which showed that demographic variables at a significance level of P < 0.05
majority participants scored lowest marks in this item and [Table 2].
were not safely practicing on it [Figure 6].
No significant difference was found between practices
Factors contributing towards medication errors with demographic variables such as age, sex,
Among all the 10 contributing factors, lack of familiarity professional qualification, number of patients/day,
to LASA was found as the most common contributing experience in pediatric area and attended any in‑service
factor with the highest mean score and standard deviation education on medication error as the calculated
of 3.28 ± 0.59, followed by lack of guidelines, poor Chi‑square value was less than the tabulated value at
handwriting of physicians, lack of training, noncompliance a significance value of P < 0.05 [Table 3]. Significant
with drug policies, lack of supervision, inappropriate difference was found between the level of practices with
labeling of drugs, failure to cross‑check when having clinical area of working as the calculated Chi‑square
doubt, failure to report medication error, and the least value was more than the tabulated value at a significance
common contributing factor found for medication errors value of P < 0.05. Among all the working areas, PICU
in children was the lack of experience with a mean score had largest proportion of safe practices and pediatric
and standard deviation of 2.72 ± 0.5 as reported by the emergency had largest proportion of moderately safe
pediatric nurses in their working areas [Figure 7]. practices related to medication errors in children. No
evidence of unsafe practices was seen in any area of
Relationship between awareness and practices
toward medication errors clinical work [Figure 8].
A weak positive correlation between awareness and
Discussion
practices toward medication errors in children among
pediatric nurses was found at significance level of Medication errors can be a significant threat to patient
P < 0.05. safety resulting in serious harm or even death of
the patients. This study was conducted to assess the
No significant difference was found between the level of awareness, practices, and contributing factors toward
awareness toward medication errors with all the selected medication errors in children among pediatric nurses.
The study findings revealed that the majority of
participants were graduate females, from the age group
of 26–30 years, working in PICU, having <1 year of
experience in their area, caring for 11–20 patients/
day and had not attended any in‑service education on
medication errors.
Most of the pediatric nurses (70%) were moderately
aware, followed by (21%) of them were highly aware
toward medication errors in children. These findings
were congruent with the findings from a study conducted
by Kaur et al.[9] in which majority of nurses (61%)
had average knowledge followed by 32% had poor
knowledge and only 8% had good knowledge regarding
Figure 6: Item wise ranking of Practices
Figure 7: Contributing factors towards medication errors Figure 8: Association between level of practices with clinical area
medication errors. The current study contrasts with the the areas such as reporting of medication errors in
study conducted by Fathi et al.[7] in which nurses had which awareness and practices toward medication
unsatisfactory knowledge toward medication errors. errors in children among the pediatric nurses needs to
be improved. The most common factor contributing
The current study found that majority (80%) of
toward medication error in children found in this
pediatric nurses were practicing safely, followed
study was lack of familiarity to LASA followed by
by (20%) were practicing moderately safely and no
the lack of guidelines. Hence, familiarity to LASA
pediatric nurses were found practicing unsafely toward

drugs, formulation of medication safety protocols,
medication errors in children which were congruent
with the findings of a study conducted by Ramya[10] organizing various training programs on medication
who revealed that the majority (69%) of staff nurses errors, promoting a blame free and nonpunitive culture
for voluntary reporting of medication errors, root cause
had good practices followed by 31% had moderate

practices toward the prevention of medication error in analysis, and filling of medication reconciliation/error
children. The current study findings were contradicted reporting form are some of the measures to improve
with the results of a study conducted by Fathi the awareness and practices toward medication errors in
et al.[7] which found that the practices of nurses were children.
unsatisfactory regarding medication administration Author contributions
errors and no significant difference was found between Ms. Sonali Singh: Contributed in literature review, tool
practices of nurses toward medication errors with formation, Data collection, analysis and interpretation
demographic variables. of results. Dr. Malar Kodi S and Mrs. Rupinder Deol:
In this study, lack of familiarity to LASA was the most Study conception and design, Contributed data or
common contributing factor and lack of experience by analysis tools; manuscript preparation
new nurses was the least common contributing factor Acknowledgments
for medication errors. These findings were congruent We are thankful to the Institutional Ethics
with the results of a study conducted by Alreshidi[11] Committee (IEC), Nursing Department of the selected
in which high workload, lack of familiarity with hospital for permitting us to conduct the study and the
medications, high patient to nurse ratio, and poor participants for their support in the study.
handwriting by doctors were the common contributing
factors toward medication errors. The current study Financial support and sponsorship
findings contradicted with the findings of a study Nil.
conducted by Baraki et al.[12] in which availability Conflicts of interest
of medication preparation room, the number of drug There are no conflicts of interest.
prescriptions/patient and availability of medication
administration guide, medications prepared without the References
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the common factors associated with medication errors Deshmukh AM, et al. Incidence of medication error in critical
were the contributing factors found for medication care unit of a tertiary care hospital: Where do we stand? Indian J
Crit Care Med 2020;24:799-803.
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2. Ambwani S, Misra AK, Kumar R. Medication errors: Is it the
Limitations hidden part of the submerged iceberg in our health-care system?
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3. Feyissa D, Kebede B, Zewudie A, Mamo Y. Medication error
(Uttarakhand), India, which limits its generalizability
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practices through self‑reporting technique which might Center, Southwest Ethiopia: Prospective observational study.
have been resulted in response bias and also this Integr Pharm Res Pract 2020;9:147-53.
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SatyaSree J, et al. Incidence of various medication errors in
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5. Acharya F, Yogananda R, Mamatha R, Priyanka N. Assessment
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Medication Errors among Medical and Dental Interns In
Medication errors in children are a critical issue which
South India. International Journal of Scientific Research in
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7. Fathi A, Hajizadeh M, Moradi K, Zandian H, Dezhkameh M, 10. Ramya E. Knowledge, attitude, and practice towards prevention
Kazemzadeh S, et al. Medication errors among nurses in of medication errors in children among staff nurses working at
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Health 2017;39:1-7. 11. Alreshidi T. Administration Errors and Their Management in
Saudi Arabian Hospitals; 2016. 141.
8. Cheragi MA, Manoocheri H, Mohammadnejad E, Ehsani SR.
Types and causes of medication errors from nurse’s viewpoint. 12. Baraki Z, Abay M, Tsegay L, Gerensea H, Kebede A, Teklay H.
Iran J Nurs Midwifery Res 2013;18:228-31. Medication administration error and contributing factors among
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knowledge regarding medication error among staff nurses at SGRD Ethiopia. BMC Pediatr 2018;18:1-8.

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Original Article

Awareness, Practices, and Contributing Factors toward Medication

Introduction errors were reported, with an error rate of 1 in every

Figure 1: Level of awareness Figure 2: Domain wise analysis of awareness

Figure 3: Item wise ranking of Awareness Figure 4: Level of practices

moderately safe with a mean score and standard

pediatric nurses were found practicing unsafely toward

had good practices followed by 31% had moderate

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