title: Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors.
abstract: 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 errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors 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 is also needed.
authors.affiliation: Academic Practice Unit, Pharmacy Department, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK. c.huynh3@aston.ac.uk.|Pharmacy Department, School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, B4 7ET, UK. c.huynh3@aston.ac.uk.
authors.forename: Chi
authors.identifier: http://orcid.org/0000-0001-6982-6642
authors.initials: C
authors.lastname: Huynh
authors.affiliation: Research Department of Practice and Policy, UCL School of Pharmacy, London, UK.|Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.
authors.forename: Ian C K
authors.initials: ICK
authors.lastname: Wong
authors.affiliation: Academic Practice Unit, Pharmacy Department, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK.
authors.forename: Jo
authors.initials: J
authors.lastname: Correa-West
authors.affiliation: Academic Practice Unit, Pharmacy Department, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK.|Pharmacy Department, School of Life and Health Sciences, Aston University, Aston Triangle, Birmingham, B4 7ET, UK.
authors.forename: David
authors.initials: D
authors.lastname: Terry
authors.affiliation: School of Pharmacy, University College Cork, Cork, Ireland.|Pharmacy Department, Cork University Hospital, Cork, Ireland.
authors.forename: Suzanne
authors.initials: S
authors.lastname: McCarthy
mesh_terms: D001359:Aviation; D002648:Child; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control*; D061214:Patient Safety