Medication Errors in a Handwritten Paper-Based Medication Workflow at a Pediatric Hospital in Kirkuk, Iraq: A Prospective Observational Study

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.