Bakr, Oral Mohammed (2026) Medication Errors in a Handwritten Paper-Based Medication Workflow at a Pediatric Hospital in Kirkuk, Iraq: A Prospective Observational Study. American Journal of Pediatric Medicine and Health Sciences (2993-2149), 4 (9). ISSN 2993-2149

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Abstract

Medication errors are an important patient-safety concern in pediatric hospitals, particularly in handwritten, paper-based medication systems where incomplete information, calculation mistakes, illegible prescriptions, and administration errors may occur. Children are especially vulnerable because many medications require weight-based dose calculations. A prospective observational study was conducted in a children's hospital in Kirkuk, Iraq, during 2026. Five pharmacists working in different hospital wards reviewed handwritten medication orders and administration records during a one-month observation period between March and May. Errors were documented and corrected during pharmacist double-checking before medicines reached patients. Patient-level missing-weight documentation and medication-related error events were analyzed separately using IBM SPSS Statistics version 26.0. Among 650 pediatric patients and 3,350 medications reviewed, 54 patients (8.31%) had missing weight documentation. An additional 293 medication-related error events were identified (8.75 events per 100 medications reviewed), giving 347 recorded safety observations in total. Administration-related events accounted for 171 of the 293 medication-related events (58.36%), followed by prescribing (80; 27.30%) and dispensing (42; 14.33%). Missed administration time was the most frequent medication-related error (142/293; 48.46%). All 347 recorded problems were detected and corrected before reaching patients. Pharmacist double-checking intercepted all documented errors before patient exposure. Mandatory weight recording, standardized paper medication charts, dose verification, and clear administration schedules may improve safety in pediatric paper-based workflows.

Item Type:	Article
Uncontrolled Keywords:	Pediatric medication safety, Medication errors, Paper-based workflow, Pharmacist double-checking, Kirkuk Iraq
Subjects:	H Social Sciences
Depositing User:	admin eprints
Date Deposited:	29 Sep 2026 04:26
Last Modified:	29 Sep 2026 04:26
URI:	http://eprints.umsida.ac.id/id/eprint/17132

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