According to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), medication error (ME) is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer (National Coordinating Council for Medication Error Reporting and Prevention, 2021). Due to their unique developmental, cognitive, medical, and pharmacokinetic characteristics, pediatric patients have a higher risk of MEs than adult patients (Grissinger, 2015). Hospitalized children may experience three times as many MEs as hospitalized adults, and these errors are frequently harmful (Kaushal et al., 2001). Such events may occur at any stage of the medication process, including prescribing, transcribing/verifying, packaging, compounding, dispensing/delivering, distribution, administration, and monitoring (Gonzales, 2010). Nurses are actively involved in patient care, especially in medication administration; medication administration is the last opportunity to correct an error before a potential ME actually occurs for a patient. As the most extensive members of the healthcare system, nurses often act as a key source of system-level resilience in improving medication safety owing to their close contact with patients throughout healthcare service (Vos et al., 2020).

High-alert medications (HAMs) are a group of specific medications that can cause significant patient harm or even death when they are used in error; this classification was proposed by the Institute for Safe Medication Practice (ISMP) (Institute for Safe Medication Practices, 2018). Compared to ordinary drugs, HAMs bear greater risks of adverse events. Through analysis of all pediatric drug-related incident reports to the Health and Social Care Inspectorate in Sweden 2011–2017, Nydert et al. (2020) found that the prevalence of incident reports involving HAMs was almost double that of nonalert substances. The ISMP developed the first list of HAMs in acute care settings in 1995, and the newest version of the list was published in 2018 (Institute for Safe Medication Practices, 2018). Several countries established their own lists of HAMs based on the ISMP list (Khoo et al., 2013; Maaskant et al., 2013; Hospital Pharmacy Committee of Chinese Pharmaceutical Assiciation, 2019), and most lists include the following classes: chemotherapeutic agents, highly concentrated electrolytes, neuromuscular blocking agents, cardiovascular medications, anticoagulants, opioids and their derivatives, and benzodiazepines. Some HAMs have a narrow therapeutic range, e.g., chemotherapeutic agents, which, when used at improper doses, may cause undesirable events; other HAMs require special administration methods, e.g., vincristine is for intravenous use only, vasoactive agents have high-level requirements for intravenous catheters, and parenteral nutrition requires a strict administration rate and monitoring of side effects. Correct and appropriate administration of HAMs is a major concern for nurses worldwide and is directly related to the safety and quality of patient care.

Insufficient knowledge among nurses is often considered to be a major factor in MEs (Tang et al., 2007), and several studies of knowledge about HAMs have been conducted among nurses (Apolinário et al., 2019; Zyoud et al., 2019). Inadequate training for nurses, negative influences from other professionals, and experiences of incorrect practice in administration indeed jeopardize medication safety. However, knowledge lays the foundation of clinical practice, and decision-making based on reasoning in the clinical context is essential for medication safety (Dickson and Flynn, 2012). According to Sulosaari et al. (2011), nurses’ medication competence consists of three major areas: theoretical, practical and decision-making competence. Ideally, clinical decisions should be made based on the best available evidence, but studies have shown that this is not always true (Goethals et al., 2012; Kozlowski et al., 2017). The traditional dual process theories emerging from the basic psychological sciences propose two kinds of thinking processes, including system 1, which is automatically activated by environmental cues, and system 2, which involves deeper processing and conscious reasoning (Weir et al., 2017). Given that decision-making is a cognitive process involving the available alternatives to solve clinical problems, it is undoubtedly affected by personal knowledge, experience and environmental factors (Choi and Kim, 2015). To the best of our knowledge, there has been no study investigating the basis of decision-making about HAM administration, both in pediatric nurses and other specialties. In addition, published data are also not available about the needs of decision support about HAM administration. Therefore, this study aims to assess the knowledge, basis of and confidence in decision-making and decision support needs regarding HAMs among Chinese pediatric nurses.

Due to the regional lockdown and social distancing rules enforced during the COVID-19 pandemic, a web-based, cross-sectional, descriptive study was conducted to explore the knowledge, confidence in decision-making, and decision support needs regarding HAM administration among Chinese pediatric nurses.

A total convenience sample of 2,518 nurses were approached, and 1,033 nurses took part in this survey, with a response rate of 41.0%. After excluding 67 questionnaires with missing data, the completion rate was 93.5%; ultimately, 966 complete questionnaires were obtained. The flowchart of participant recruitment is shown in the Supplementary Material.

This is the first study to provide data not only about the knowledge of HAM administration and management among Chinese pediatric nurses but also the basis of and confidence in decision-making and the needs for decision support about HAM administration. Our findings revealed that Chinese pediatric nurses had higher knowledge of HAMs than nurses in other countries (Kim and Kim, 2019; Zyoud et al., 2019; Salman et al., 2020). Compared to physicians in Pakistan, Chinese pediatric nurses’ knowledge of HAMs was better, with 76.4% of the nurses possessing excellent knowledge (Mustafa et al., 2022). Nevertheless, special attention should be given to the lower score for HAM regulation and the three lowest-scoring items. In fact, with the development and implementation of HAM strategies, especially information technology, including computerized prescriber order entry (CPOE), electronic medication administration records (eMAR), and barcode medication administration (BCMA), MEs in the prescription stage have been significantly reduced, making MEs in other stages of the medication process, such as preparation, distribution, administration and monitoring, an increasing proportion of all MEs (MacKay et al., 2016). Inadequate knowledge of HAMs might cause MEs, leading to poor patient outcomes. Similar to findings in Pakistan (Salman et al., 2020) and Palestine (Zyoud et al., 2019), the knowledge score of HAM regulation in Chinese pediatric nurses was significantly lower than that of HAM administration, indicating the need to improve nurses’ knowledge about HAM regulation.

The finding on the three lowest-scoring items regarding HAMs was alarming. For example, surprisingly, only one-fifth of the participants chose the right answer to the item about the fentanyl patch, which was much lower than in other countries (Zyoud et al., 2019; Salman et al., 2020; Mustafa et al., 2022). The fentanyl patch is a conventional narcotic for pain relief in adults and has several advantages, including effectiveness, good tolerance, and a long duration of action. Fentanyl-related overdose, however, has been a well-known global concern, and a recent study showed a 5.1-fold increase in fentanyl patch utilization in Australia between 2003 and 2015 (Rahman et al., 2021). Research on the pharmacokinetics and tolerability of fentanyl patches in pediatric patients has been carried out in other countries (Hiyama et al., 2021), but the patch has not yet been approved for pediatric and adolescent use in China. The U.S. Food and Drug Administration also warned of the potentially deadly exposure of fentanyl patches in children (Food and Drug Administration, 2021). In addition, 65.7% of the participants agreed with the existence of multiple concentrations to choose from for each drug, which was much higher than the percentage in previous studies (Zyoud et al., 2019; Salman et al., 2020; Mustafa et al., 2022). However, multiple concentrations and multiple dosing options may be potentially serious sources of preventable medication errors, particularly for pediatric patients receiving HAMs (Zyoud et al., 2019; Irwin et al., 2008). Early in 2004, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) in the United States recommended that hospitals stock and prepare a limited number of standard concentrations of drugs (Rich, 2004). This is especially important in pediatric acute care where errors in the calculations and preparations of individual medications in a limited time are likely to occur. Using a limited number of standard concentrations of drugs would reduce the potential for errors in solution preparation. The three lowest-scoring items provided evidence about the insufficient knowledge of nurses regarding the management of fentanyl skin patches and the error-prone use of multiple concentrations and multiple dosing regimens, indicating the need for additional continuing education and professional training on HAMs, especially for nurses who are younger, have less experience in pediatric nursing, and have a lower level of seniority.

Regarding the basis of decision-making about HAMs, our study showed that drug instructions and drug handbooks were the most frequent choices for Chinese pediatric nurses. Drug instructions should be valid, reliable, and legal texts that could guide healthcare professionals in prescription and administration and help patients to use drugs rationally. However, this is not always the case. Studies showed that there were deficiencies in the current drug instructions, including the absence of necessary content, unclear and too many nomenclatures, slow updates, and deviations from the current clinical guidelines (Chinese Clinical Medication Safety Group of International Network for the Rational Use of Drugs, 2019). More importantly, the off-label use of drugs is common in pediatrics around the world, whether in hospitals or outpatient clinics (Cui et al., 2021; Guidi et al., 2021). Therefore, drug instructions are not an ideal basis for pediatric nurses to make decisions for HAMs, let alone drug handbooks, which are potentially insufficient in terms of accuracy and timeliness. Approximately half (54.6%) of the participants considered clinical practice guidelines to be the basis of decision-making. However, clinical practice guidelines, even nationally approved guidelines, such as the United Kingdom’s Injectable Medicine Guide, might have problems with clear expression and comprehension for nurses (Jones et al., 2022). Interestingly, although the nurses’ decision-making basis about HAMs of nurses was not ideal, 84.7% of the participants reported high confidence in the decision-making about HAMs in our study, especially those who were older, having longer experience in pediatric nursing, having higher knowledge of HAMs, in position than primary nurse, having children and higher level of seniority. The improper basis of decision-making about HAM administration is extremely worrying.

To provide better support, it is essential to understand nurses’ most difficult decisions regarding HAMs. Our results showed that the most difficult decision nurses encountered when administrating HAMs was regarding the appropriateness of prescriptions. According to the Danish Patient Safety Database, Rishoej et al. (2017) described MEs in pediatric inpatients in a 5-year period, and the results showed that prescription MEs still constituted the largest part (40.8%) of all MEs. A study in China also revealed commonly inappropriate drug prescriptions in pediatric patients (Cui et al., 2021) According to the Chinese Nurses Regulation, if Chinese nurses find that a prescription violates the current laws, regulations, or standards, they should promptly report it to the responsible doctor before implementation (State Council of the People’s Republic of China, 2008). Considering the challenges faced by nurses in assessing the correctness of doctors’ prescriptions, it is understandable that nurses considered the correctness of medical orders to be the most difficult and stressful part of HAM decision-making.

In addition, the most difficult decision-making about HAMs in our study also included checks, preparation, administration, assessment, monitoring and health education, almost the entire process of medication administration. This corresponded to the high needs (92.0%) for decision support about HAMs in our results. In 2018, the American Society for Parenteral and Enteral Nutrition recommended providing clinical decision support to healthcare professionals at the time of parenteral nutrition prescription, order verification, compounding, and administration to avoid possible adverse consequences (Vanek et al., 2018). In a qualitative study about HAM administration, Sessions et al. (2019) found that current HAM safety strategies were not consistently used and recommended that education on safe HAM practices, technology enhancement, and organizational culture updates should be carried out to prevent HAM errors. In our study, the most popular types of clinical decision support were computerized CDSSs (46.4%) and real-time online communication with pharmacists (23.5%). The CDSS could facilitate evidence-based practice and greatly improve the quality of health care (Sim et al., 2001). Moss and Berner (2015) developed CDSS tools for nurses during medication administration, alerting nurses about the correct administration and monitoring of particularly dangerous aspects, such as the “Push IV dose over 4–5 min” for morphine. Such a strategy might be an opportunity to provide timely decision support for nurses during medication administration.

Ensuring the medication safety of pediatric HAMs is a complex and multistep process, and pediatric nurses are in a pivotal position to prevent MEs. This study demonstrated the deficiency of pediatric nurses’ HAM knowledge, especially of HAM regulation, and the inadequate basis of and difficulty of decision-making about HAMs. Chinese pediatric nurses have a high demand for decision support about HAMs. These findings should be used to address current problems and inform possible strategies for safe practice. Nurses need more support in HAM administration, including not just training but also adequate technology, interprofessional collaboration, and organizational culture.