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Ther Clin Risk Manag. 2017 Mar 23;13:345-353. doi: 10.2147/TCRM.S128504. eCollection 2017.

Effects of sharing information on drug administration errors in pediatric wards: a pre-post intervention study.

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Department of Pharmacy, Faculty of Medicine, University of Malaya.
Pharmacy Department, University Malaya Medical Centre.
Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.



Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems.


This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2.


A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; P<0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 (P<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors.


This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors.


drug administration error; intervention; medication error; pediatric; sharing

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

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