Since the publication of "To Err Is Human: Building a Safer Health System" in 1999, there has been much research conducted into the epidemiology, nature and causes of medication error in children, from prescribing and supply to administration. It is reassuring to see growing evidence to improve medication safety in children, however based on media reports, it can be seen that serious and fatal medication errors still It is important to educate future healthcare professionals of medication error and human factors to prevent these from happening.Further research is required to apply aviation's "black box" principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events.International sharing of investigations and learning are also needed.3
Key PointsMedication errors in children are complex; they may involve and affect more than just the patient and healthcare professional, as the parent may also be involved in their occurrence.Fear of litigation and lack of immunity hinders and deters healthcare professionals from voluntarily reporting medication errors.The way forward to prevent medication errors in children requires increased learning by healthcare professionals from adverse events and near misses as well as increased education on human factors. Education should also be expanded to the public to increase awareness of patient safety.
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