Guide to Pediatric Medication Safety

Pediatric medication errors, such as incorrect dosages, can occur in a wide range of healthcare settings, including hospitals, outpatient clinics, emergency departments and at home. Due to certain risk factors in children, such as their size, medication errors can lead to serious and potentially life-threatening adverse reactions. According to The Joint Commission, potential adverse drug events occurred as much as three times more often in pediatric patients than adult patients. 

Administering and dispensing medication to pediatric patients has unique challenges, which raises the risk of medication errors. In many cases, formulating and packaging medications is done for the adult population rather than children. Making these medications safe for children involves carefully determining and adjusting dosages. Other challenges include the fact that children’s immune systems, renal functions, and hepatic functions are still developing, which can make it more difficult for them to tolerate medication errors. They may also have a harder time communicating about any side effects or reactions they are experiencing when taking medication.

Improving administration and dispensing of pediatric medication in medical facilities and in the home can help reduce the risk of pediatric medication errors. Pediatric medication safety training programs for healthcare workers and the use of technology offer important ways to lower the risk of medication inaccuracy. The following information can help pharmacies, hospitals, and other healthcare facilities promote pediatric medication safety. 

Medication Administration and Dispensing

Administering and dispensing medication to pediatric patients entails a higher risk for error when certain factors are not considered. Healthcare workers and pharmacists can lower the risk in the following ways. 

Pediatric Safety or Approval Confirmation

Confirming which drugs are safe or approved for use in children is the first step in promoting medication safety. Pharmacists and other healthcare workers who oversee drug administration and dispensing should ensure that all medications given to pediatric patients are considered safe or have been approved by the FDA for its intended use. Confirming this information can help reduce the risk of having children take medications that are unsafe or not approved.

Dosing Factors

When determining the proper medication dosage for pediatric patients, pharmacists and other healthcare providers should consider the following factors:

  • Patient’s weight
  • Patient’s age
  • Body surface area
  • Clinically approved weight-based dosage ranges

When calculating pediatric medication dosages, especially for liquid medicines, weight is often used rather than age. Using weight-based ranges can offer a more accurate way to determine the correct dosage for children instead of basing dosages on age due to variations in body size at different ages. Utilizing body surface area to determine dosage involves considering a patient’s height and weight, which can provide a more accurate drug dosage.

Appropriate Dosage Form

Improving pediatric medication safety involves determining the appropriate dosage form for different prescription medications. Pharmacists and other healthcare workers should determine whether a tablet or liquid form is more appropriate for pediatric patients. Several factors, including age, should be considered. Liquid forms are typically used for infants and younger children, while tablet forms may be appropriate for older children. Regardless of whether tablet or liquid forms, the dosage should be accurate.

Medication Labels

Medication errors can occur due to unclear or incorrect information on labels. When determining the content for pediatric medication labels, pharmacists and other healthcare workers should ensure that the following information is clearly stated:

  • Name of medication
  • When to take medication
  • How much medication to take
  • Proper storage instructions
  • Possible side effects or reactions of medication
  • Warnings about allergic reactions to medication ingredients
  • What to do if a patient misses a dosage

Ensuring that all relevant information is included on the label helps decrease the risk of patient harm, due to medication errors or adverse drug reactions.

Medication Error Factors

Hospital and healthcare workers should also be familiar with the factors that may contribute to pediatric medication errors. Recognizing these factors and avoiding them can significantly reduce the risk of patient harm. Examples of these factors include the following:

  • Do not abbreviate or shorten the names of medications on labels
  • Do not place a zero after a whole number, such as 1.0 or 2.0, since this can cause confusion about dosage amounts
  • Place a zero to the left of a decimal point if required, such as 0.1 or 0.2 mg, to avoid confusion over dosage amounts

Side Effects and Adverse Reactions

When determining the content for pediatric medication packaging and labeling, potential side effects and adverse reactions must be clearly communicated. This content should include a list of side effects, both common and rare, that may occur when a medication is consumed. Possible adverse reactions also need to be listed, along with the signs and symptoms associated with the reactions. Pediatric medication labels and packaging should also provide clear instructions on what to do if patients show any signs or symptoms of adverse effects, such as contacting a physician or seeking emergency medical services. This helps to ensure that family members who are administering medication to children know how to handle an adverse event if one occurs. 

Create a Pediatric Medication Safety Training Program

Having a pediatric medication safety training program in place helps to ensure that healthcare staff are prepared to administer or dispense medication orders as safely as possible. Healthcare directors can implement these programs as part of a commitment to improving pediatric medication safety. When creating these programs, healthcare directors consider the following guidelines.

Make the Program Mandatory for New Staff

New staff members should go through the pediatric medication safety training program. Including this training as part of the process for onboarding new staff can help reduce the risk of medical errors among the pediatric population. Once staff have completed this training program, they should be knowledgeable about safely administering and dispensing medication to pediatric patients.

Include Early Exposure to Pediatric Patients in Pharmacist Training Programs

Pharmacist training programs should provide opportunities for trainees to have early exposure to pediatric patients. This allows trainees to gain experience treating young patients and learn more about safety protocols when administering and dispensing pediatric medication.

Develop Pediatric Drug Lists for Specific Facilities

Pharmacists and other healthcare staff should create a list of pediatric drugs that are specific to their facility. For example, an emergency department might have a different list of medications as opposed to an oncology unit in a pediatric hospital. Staff should  evaluate the list developed and focus on determining which medications are considered high-risk for that specific facility. This information can help lower the risk of pediatric medication errors and improve pediatric patient safety.

 Use External Resources

External resources from The Joint Commission, the National Coordinating Council for Medication Error Reporting and Prevention, and other organizations provide valuable information on pediatric medication safety. Utilizing these resources can help to ensure that pharmacists and other healthcare workers are up to date on the latest pediatric advisory recommendations and changes to pediatric medication labeling. This information should be communicated to any staff members that manage pediatric medication at hospitals and other facilities to reduce the risk of errors. 


The use of technology can significantly improve pediatric patient safety when medications are administered or dispensed. In some cases, technology can reduce the risk of human errors that can lead to incorrect dosages or other pediatric medication errors.

Improve Overall Safety

Pharmacists and healthcare directors should choose software programs and other technology that helps to improve overall safety and reduces the risk of preventable harm in administering and dispensing medication. Smart pumps and similar technological devices for healthcare facilities can help to provide an appropriate dose of medication to pediatric inpatients. However, these devices should not be considered a guarantee that medication errors will not occur. Any technology utilized to improve medical care should be used correctly and checked regularly to make sure errors are not occurring.

Use Automation

Using automation, such as computerized physician order entry, clinical decision support tools, and pharmacy automation, can improve dosage accuracy and other factors that help prevent medication errors. These tools can dispense the correct dose of pediatric medication, sync patient records, automate medication reconciliation, and handle other medication safety tasks. Automation used in a hospital pharmacy should be checked regularly for accuracy to prevent errors.

Reduce Medication Errors

Technology that is used for lowering medication errors is typically designed for adult medication. As with the formulation and packaging of pediatric drugs, this technology needs to be adapted for pediatric medication. Technological advances such as barcoding typically requires careful adjustments for use with pediatric medications.

Medical Packaging Inc., LLC (MPI) is dedicated to helping healthcare professionals reduce the risk of pediatric medication errors. MPI offers high-quality unit dose medication and pharmaceutical packaging and labeling systems, MPI-certified consumable materials, and other products to help pharmacies, hospitals, and other medical facilities ensure pediatric medication safety. Contact MPI to learn more about medical packaging solutions.