of ambulatory institutions need to be developed. Even the effect of electronic prescribing on medication safety in the ambulatory setting has not been well studied; the same is true of the impact of providing different levels of decision support. Effectiveness studies of the most promising error prevention strategies are needed, with priority given to electronic prescribing with clinical decision support and collaborative care approaches involving physicians, nurses, and pharmacists, and with patient self-education/counseling.

The majority of patient–pharmacy interactions on a day-to-day basis involve prescription refills. There is a need for studies targeting safe practices in this area. Also needing study are the effects of time demands on clinicians in the ambulatory setting on safety in general and on medication safety in particular.

Pediatric Care

Standardization of recommended doses for children is essential to enable providers, researchers, and developers of technological prescribing solutions to speak a common language as to what doses are considered acceptable (that is, not errors) for children (McPhillips et al., 2005a,b). Despite the push for CPOE and electronic prescribing, the lack of uniformity on standard pediatric doses is at least part of the reason for the usual absence of pediatric-specific dosing tables powering most commercially available CPOE tools. Because of the inability to build such dosage rules into computerized prescribing tools, children cannot reap the full benefit of information technology in the medication delivery process.

In the home environment, research is needed on standardization of concentrations and dosing spoons, syringes, and other tools used by parents and guardians, similar to the efforts now under way to standardize and limit the number of concentrations used within institutions.

Most of the research to date on pediatric medication errors has been skewed toward prescribing errors. The committee’s review of data from error reporting systems revealed that dispensing and administering are as error prone as prescribing. In contrast with the medication-use process for adults, the steps of dispensing and administering in pediatric populations depend much more heavily on manual compounding of liquid medications and administration to patients who are unable to perform their own medication safety checks. Understanding the unique risks for children in these two steps is critical to determining which interventions will eliminate or mitigate these risks.

Many potential approaches to error reduction are relatively inexpensive and are supported by common sense based on knowledge of human factors. Such approaches include representation of pediatric care on for-



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