FL: Preventing Medical ErrorsPage 7 of 12

5. Vulnerable Populations

Children are at particular risk of medication errors . . . this is attributable primarily to incorrect dosages.

Institute of Medicine [sic], 1999
To Err Is Human: Building a Safer Health System

Anyone who takes medication has some risk of a harmful effect. There are some groups, however, that have an increased risk of adverse medication events. Children, elders, and those with limited English skills and/or poor health literacy are at a high risk for adverse events.


Approximately 200,000 children (17 years old or younger) visit emergency departments each year because of adverse drug events. Children less than 5 years old are more likely than older children to visit the emergency department for an adverse drug event (approximately 60,000 each year), and each year 1 in every 150 two-year-olds visits an emergency. Nearly 70% of emergency department visits for unsupervised medication ingestions by young children involve 1- or 2-year-old children (CDC, 2018k).

Pediatric patients face four distinct issues that set them apart from the rest of the hospital population, making it a high-risk environment for hospitalized children:

  • Development. As children mature both mentally and physically, their needs for healthcare goods and services change.
  • Dependency. Hospitalized children are dependent on caregivers and parents to convey key information and their care must be approved by parents or their surrogates during all encounters.
  • Different epidemiology. Most hospitalized children require acute episodic care, not care for chronic conditions as with adults.
  • Demographics. Children are more likely to live in poverty and experience racial and ethnic disparities in healthcare, and they are more dependent on public insurance (Hughes & Blegen, 2008).

Medication errors are the most common adverse event experienced by pediatric inpatients. Often pediatric indications and dosage guidelines aren't included with a medication, necessitating weight-based dosing or dilution, which in turn creates more opportunity for error (PSNet, 2015; Hughes & Edgerton, 2005; AHRQ, 2009).

In a study published in Pediatrics in August 2018 a review of data from 2007–2012 concluded that adverse event rates in pediatric inpatients are high and did not improve from 2007 to 2012. In addition, the rates were substantially higher in teaching hospitals and in patients with more chronic conditions (Stockwell et al., 2018).

In the same issue commenters noted that, while some collaboratives have made gains in addressing the problem, there is concern that adverse events in children are underreported. This may be because most reporting is passive and voluntary while in the Stockwell study uses tools known as “triggers,” which actively detect AEs and detect errors at a higher rate than do passive methods (Quinonez & Schroeder, 2018; Walker, 2018).

Preventing Medical Errors for Pediatric Inpatients

Children are not simply little adults; their physiology and mental development are vastly different from adults. While many of the same medical error prevention techniques for adults are perfectly acceptable for pediatric patients (eg, hand hygiene), others need more consideration.

In January 2019 the Child Patient Safety Organization (PSO) published their 2018 annual report identifying

Patient Care Vulnerabilities for Hospitalized Children

  • NG Tube Misplacement
  • MRI Safety
  • Retained Foreign Objects
  • Communication Failures
  • Behavioral Health
  • Diagnostic Safety and Cognitive Bias
  • Wrong-Site Surgeries and Procedures
  • Medication Safety
  • Thermal Injuries
  • Diabetes Care Management (CHPSO, 2019)

The report provides additional information and links to resources, including those offered by the PSO itself.


Elderly patients are prescribed more than 30% of all prescription drugs. Adverse drug events or reactions to medicines are implicated in 5% to 17% of inpatient admissions (Alexander & Wang, 2014).

Elders in the Community

For many older adults in the community, the ability to remain independent in their homes depends on the ability to manage a complicated medication regimen. Non-adherence to medication regimens is a major cause of nursing home placement in older adults. In the United States, an estimated 3 million older adults are admitted to nursing homes due to drug-related problems, at an annual cost of more than $14 billion (Hughes & Blegen, 2008).

As people age, they typically take more medicines. Older adults (>65 years) come to emergency departments almost 450,000 each year, more than twice as often as younger people, and they are nearly 7 times more likely to be hospitalized after an emergency visit (CDC, 2018m).

Most of these hospitalizations are due to just a few drugs that require careful monitoring to prevent problems. These include blood thinners such as warfarin, diabetes medications like insulin, seizure medications such as phenytoin and carbamazepine, heart medicine such as digoxin, and opioid analgesics (CDC, 2018m).

Poor cognition is associated with inability to follow medication regimens. Forgetting is a major reason medication doses are missed. The most common type of noncompliance is dose omission, but over-consumption is also a mistake frequently made by older people (Hughes & Blegen, 2008).

Older adults have narrow therapeutic windows and require close monitoring, especially when on multiple medications. A review of emergency department visits of patients 65 years and older found that more than 10% of the visits were related to an adverse drug event and more than 30% had at least one potential adverse drug interaction in their medication regimen (Hughes & Blegen, 2008).

Poor vision and decreased manual dexterity are also problems for elders. It is common for medication bottle caps to be left off or not properly closed so the patient can access the medicine. One study showed that almost one-half of older patients stated that they were not able to read the labels on the bottles due to poor eyesight, inability to read English, or small writing on the bottles (Hughes & Blegen, 2008).

Another cause of non-adherence in elders is difficulty with medication procurement. In a study of elders at 15 days after hospitalization, 27% had not filled their new prescriptions (Hughes & Blegen, 2008).

Preventing Medical Errors for Elders in the Community

Medication reconciliation is the first step in helping older adults with medication management. Multiple studies have shown discrepancies as high as 66% in medications that were ordered and those actually being taken (Hughes & Blegen, 2008).

Pharmacy resources, such as medication reviews and computerized medication interactions programs, are effective tools to reduce adverse drug events in older patients. Patients who participate in pharmacy delivery programs and refill reminders have higher compliance than those who do not (Hughes & Blegen, 2008).

Hospitalized Elders

The older patient has increased risk for functional decline during hospitalization due to decreased mobility and other risks of hospitalization. They may also experience delirium due to a medical condition, leading to cognition issues in compliance with care. Beyond medication errors, frail elders in the hospital have a higher risk for falls, hospital-acquired infections, and pressure ulcers (Hughes & Blegen, 2008).

Preventing Medical Errors for Hospitalized Elders

The elderly acute-care patient will benefit from the same medical error preventions as the rest of hospital population, but particular attention should be paid to falls, pressure ulcers, and hospital-acquired infections. Those older than 65 with cognitive issues have the greatest risk for falls in the acute-care setting (Hughes & Blegen, 2008). (see Medical Errors, Patient Falls section)

Elders are also among those at highest risk for pressure ulcers. Interventions for preventing pressure ulcers can include good skin hygiene and frequent position changes (see earlier section, Medical Errors, Pressure Ulcers) (MedLine Plus, 2018).

Patients with Limited Health Literacy

Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” It includes the ability to understand instructions on prescription bottles, appointment slips, medical education brochures, doctors’ directions, and consent forms, and the ability to negotiate complex healthcare systems (NN/LM, n.d.).

More than 90 million adults in the United States have low health literacy (MedlinePlus, 2018a). The burden of health literacy on those who have difficulty understanding English is enormous. Nearly 25 million people in the United States (8.6%) are defined as limited English proficient, meaning that they speak English less than "very well." Therefore, at least 8.6% of the U.S. population is at risk for adverse events because of barriers associated with their language ability (Betancourt et al., 2012).

The Joint Commission notes that “health literacy issues and ineffective communications place patients at greater risk of preventable adverse events.” Studies have shown that lower health literacy is linked to a lower likelihood of getting flu shots and of understanding medical labels and instructions, and a greater likelihood of taking medicines incorrectly. It is also linked with poorer health status, less use of preventive care, more likelihood of hospitalization, and bad disease outcomes. The annual cost to the U.S. economy of low health literacy is estimated to be between $106 billion and $238 billion (NN/LM, n.d.).

Populations most vulnerable to poor health literacy include:

  • Older adults
  • Immigrant populations
  • Minority populations
  • Low income populations (NN/LM, n.d.).

Preventing Medical Errors in Those with Limited Health Literacy

The AHRQ recommends use of its Health Literacy Universal Precautions Toolkit. The Universal Precautions approach involves:

  1. Creating a shame-free environment
  2. Simplifying information
  3. Listening carefully
  4. Confirming comprehension
  5. Improving support for navigating healthcare contexts
  6. Supporting patients in their health management efforts (PSNet, 2019c; AHRQ, 2015)

The toolkit with accompanying resources can be downloaded from AHRQ here:


Other similar tools are available from CDC and Health Resources & Services Administration (HRSA).

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