Keeping Pediatric Patients Safe

modified November 2025

Med errors are three times as likely to occur in infants and children than in adults. Up to one in four pediatric med orders results in an error, and just over 5% of pediatric inpatients may experience a med error.1-3,5 About one-third of med errors in kids have the potential to cause serious harm.9 Many aspects of pediatric med use (e.g., weight-based dosing, lack of commercially available dosage forms, complex calculations) pose safety challenges.1-4 General safety strategies (e.g., tall man lettering) should always be used. In addition, regulatory and safety groups recommend maintaining current pediatric drug info resources, ensuring appropriate 24-hour coverage of pediatric pharmacy services, and including a pharmacist with pediatric training in oversight of technology (e.g., smart pumps, clinical content of electronic health records [EHRs]) and med use committees.1,4 The following chart provides strategies to prevent med errors in pediatric patients in both inpatient and outpatient settings.

    

Prevent ordering errors
    

Ensure that a medication and vaccine history is conducted for pediatric patients by a pediatric pharmacist, whenever possible.1,9

Check that heights and weights are correct, and documented in metric units (e.g., kg) only.1,6

  • Patients should be weighed often (e.g., with new outpatient prescriptions, at inpatient admission [or within four hours of admission]).4,6
  • Ensure that weights are kept current (e.g., infants may require daily weights) during prolonged admissions and with chronic meds.

Use only metric units when ordering and giving directions for pediatric medications (e.g., mL instead of teaspoons).1,8

Ensure that pediatric doses are ordered as dose per weight (e.g., mg/kg) rather than just the total dose.4,8,9

Standardize and limit the number of concentrations of meds for pediatric patients, especially high-alert meds.4


Avoid verbal orders whenever possible.1

For handwritten orders, avoid the use of naked decimals (e.g., .1) or trailing zeros (e.g., 1.0) to prevent ten-fold dosing errors.5,9

Inquire about adding weight-specific and age-specific dosing alerts to your EHR, if they aren’t already being used.1,4,5

Prevent dosing errors

Ensure that parents or caregivers understand all administration instructions, including which measuring device to use and how to measure the dose of liquid medications.11

Be aware of general age definitions used in pediatrics, which is commonly described as patients from birth to 18 years:8

  • a preterm neonate is born at <37 weeks gestation.
  • a neonate is <1 month old.
  • an infant is 1 month to 1 year old.
  • a child is 1 to 11 years old.
  • an adolescent is 12 to 18 years old.

Clarify if your EHR’s reference ranges for vital signs and labs default to adult values for all patients. If so, ask if these can be adjusted to normal ranges for pediatric patients, when appropriate.8

  • As a rule of thumb, pediatric respiratory and pulse rates are higher than adults, blood pressure is lower than adults, and body temperatures are the same.8

Use an appropriate drug reference for premature babies and neonates. Examples include NeoFax and Pediatric & Neonatal Dosage Handbook. Don’t rely on adult drug information references for these patients.

Use weight-based dosing for pediatric patients. But most pediatric doses should be capped at adult doses, even if a pediatric patient’s weight-based dose is higher than an adult dose.8,9

  • Reassess chronic med doses frequently, as a patient’s height and weight increase.8

Stay alert for mix-ups between units when calculating doses, such as mg/kg/DAY and mg/kg/DOSE.8,9

Stay alert for confusion with combination meds. For example:

  • piperacillin/tazobactam mg/kg doses for pediatric patients are based only on the piperacillin component.
  • amoxicillin/clavulanic acid products come with the components in different ratios that impact dosing frequency.

Ensure dose volumes are appropriate. For example, for IM injections, use a max of 0.5 mL in neonates and a max of 1 to 2 mL in children.10

  • If needed, divide doses between multiple syringes to avoid exceeding the max volume for a single injection.10

Use (and ensure your EHR is using) a pediatric equation (e.g., Schwartz, Bedside Schwartz) to assess kidney function.

  • Avoid using adult equations, which can overestimate in pediatric patients.9
  • Small changes in serum creatinine can be more significant in pediatric patients than in adults.8

Prevent compounding errors

Stock commercially available products for pediatric patients when they’re available, to avoid the need for compounding.1,4

Stick to standardized concentrations for liquid meds (orals and injectables), whether they’re commercially available or compounded.1

  • Example: The recommended concentration for compounded atenolol oral liquid is 2 mg/mL.7

When compounded meds are necessary, ensure that the pharmacy compounds them. Avoid having parents, caregivers, nurses, or others compound pediatric meds.1

Separate compounding of pediatric and adult doses.4

  • Example: Avoid prepping adult and neonatal parenteral nutrition in the same IV hood at the same time.

Prevent dispensing and administration errors

Store adult and pediatric meds separately, whenever possible.4

  • Avoid stocking adult concentrations of meds on pediatric patient care units such as in automated dispensing cabinets.4,9
  • Example: Stock pediatric strengths of injectable vitamin K (1 mg/0.5 mL) instead of adult strengths of vitamin K (10 mg/mL) in automated dispensing cabinets in neonatal patient care areas.

Dispense patient-specific doses for pediatric patients whenever possible, and minimize necessary manipulation (e.g., splitting tablets) prior to administration.1,2,4,5,9

  • If manipulation is necessary after a med is dispensed, provide clear instructions.5

Ensure inpatient unit-dose packages have readable bar codes for scanning prior to administration.1,2,4

Dispense oral liquids in oral syringes to reduce the risk of accidental injection.4,6

Ensure your hospital has a policy on in-house use of insulin pumps.1

Ensure smart pumps are programmed with appropriate dose limits and hard stops for pediatric patients, and that libraries are maintained and reviewed at least once a year.1,3,5,9

  • Advocate for syringe pumps or modules in your hospital for accurate administration of very small volumes such as <0.1 mL/h.9

Avoid workarounds with bar-code scanning during med prep and administration.1 Help identify and prevent issues such as difficulty scanning bar codes on labels on smaller med packaging, etc.1

Make sure oral syringes are available on patient care units in case an oral liquid dose would need to be drawn up by a nurse or other clinician.4,6

Recommend labeling IV lines with the name of the med being infused to prevent mix-ups, especially if tubing has to be detached.5

Use extra precautions in high-risk situations

Be aware that some medications and excipients may potentially be inappropriate in pediatric patients.

Keep in mind that children younger than five years old are most likely to experience med errors.5

Stay alert for age-appropriate dosing in areas where both pediatric and adult patients might be treated (e.g., outpatient pharmacies, perioperative areas, emergency department).4,5

  • Ensure high-risk meds (e.g., insulin, opioids) are not able to be auto verified for pediatric patients.

Keep in mind that intensive care units (e.g., neonatal ICU, pediatric ICU) are high-risk areas for medication errors.5

Be aware of meds that are most likely to be implicated in pediatric medication errors.

  • Example: Pediatric med errors seem most likely with antibiotics, IV fluids, opioids, and vaccines.5 High-alert meds that seem most likely to be implicated in pediatric med errors include insulin, opioids, and parenteral nutrition.5

Prevent errors in inpatient emergency situations

Keep meds for pediatric cardiac or respiratory arrests separate from adult meds.

Preprint weight-based dosing sheets for emergency meds for pediatric patients and have them available at bedside.4

Ensure teams such as CPR, emergency preparedness, rapid response, and trauma include a pediatric pharmacy representative.1

Ensure that a pharmacist with pediatric training participates in pediatric codes, and has appropriate training (e.g., pediatric advanced life support).1

Safely manage pain in pediatric patients

Assess pain using scales and tools specifically designed for the patient’s age.12

  • Consider patient behavior, physiologic measures, facial expressions, parental assessment, and patient self-report.12

Encourage parents/caregivers to try non-med pain relief strategies: distractions (e.g., videos, movies, games); repositioning, rocking, or stroking the child; or singing to them or providing soft music.13

See our checklist, Vaccine Administration Strategies, for more non-med ways to minimize injection pain.

Choose acetaminophen or ibuprofen for most types of pain in pediatrics.14

Avoid potentially harmful analgesics (e.g., topical benzocaine [for teething], codeine, and tramadol).15

Use strong opioids appropriately, and only when non-opioids are not enough.16

See our chart, Potentially Harmful Drugs in Children for details and alternatives.

References

  1. Eiland LS, Benner K, Gumpper KF, et al. ASHP-PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. J Pediatr Pharmacol Ther. 2018 May-Jun;23(3):177-191.
  2. Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics. 2014 Aug;134(2):338-60. Erratum in: Pediatrics. 2015 Sep;136(3):583..
  3. Manias E, Kinne S, Cranswick N, et al. Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother. 2014 Oct;48(10):1313-31.
  4. The Joint Commission. Sentinel Event Alert. Preventing pediatric medication errors. Issue 39, April 11, 2008. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_39.pdf. (Accessed May 24, 2023).
  5. Grissinger, M. Medication errors affecting pediatric patients: unique challenges for this special population. Pa Patient Saf Advis. 2015 Sep;12(3):96-102.
  6. ISMP. 2018-2019 targeted medication safety best practices for hospitals. https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdf. (Accessed May 24, 2023).
  7. ASHP. ASHP compounded oral liquid version 1.10. July 2017. https://www.ashp.org/-/media/assets/pharmacy-practice/s4s/docs/s4s-ashp-oral-compound-liquids.ashx. (Accessed May 24, 2023).
  8. Eiland LS, Meyers RS. Caring for and assessing pediatric patients: Aspects to consider as a pharmacy practitioner. Am J Health Syst Pharm. 2019 Sep 16;76(19):1463-1471.
  9. Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital setting. Am J Health Syst Pharm. 2019 Sep 16;76(19):1481-1491.
  10. Losek JD, Gyuro J. Pediatric intramuscular injections: do you know the procedure and complications? Pediatr Emerg Care. 1992 Apr;8(2):79-81.
  11. Boyle KL, Rosenbaum CD. Oxycodone overdose in the pediatric population: case files of the University of Massachusetts Medical Toxicology Fellowship. J Med Toxicol. 2014 Sep;10(3):280-5.
  12. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001 Sep;108(3):793-7.
  13. National Hospice and Palliative Care Organization. Nonpharmacological pain management for children. 2017. https://www.nhpco.org/wp-content/uploads/2019/04/PALLIATIVECARE_Nonpharmacological.pdf. (Accessed May 24, 2023).
  14. Marcellusi A, Ragonese A, D'Avino A, et al. Optimising pediatric paracetamol and ibuprofen use: a retrospective study with expert evaluation of efficacy, safety, and healthcare costs. Glob Reg Health Technol Assess. 2025 Oct 7;12:227-233.
  15. McPherson C, Meyers RS, Thackray J, et al. Pediatric Pharmacy Association 2025 KIDs List of Key Potentially Inappropriate Drugs in Pediatrics. J Pediatr Pharmacol Ther. 2025 Aug;30(4):422-439.
  16. Trottier ED, Ali S, Doré-Bergeron MJ, Chauvin-Kimoff L. Best practices in pain assessment and management for children. Paediatr Child Health. 2022 Dec 9;27(7):429-448.

Cite this document as follows: Clinical Resource, Keeping Pediatric Patients Safe. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber’s Letter. June 2023. [390616]