Pharmacists Reach Landmark Consensus on Child Medication Safety Priorities

Children are not simply small adults, and nowhere is that maxim more consequential than in the prescribing, dispensing, and administration of medicines. Weight-based dosing, age-dependent metabolism, limited pediatric formulations, and the frequent off-label use of drugs designed and tested for adults all combine to make pediatric patients uniquely vulnerable to medication errors. In Saudi Arabia, where attention to medication safety has grown steadily in recent years, one persistent problem has remained: nobody had systematically asked the frontline experts which interventions should come first. A new study published in BMC Pediatrics set out to close that gap, and its findings offer one of the clearest roadmaps to date for protecting hospitalized children from preventable drug-related harm.

The research, led by Ghadah H. Alshehri of Princess Nourah bint Abdulrahman University in Riyadh together with colleagues from Taif University, Prince Sultan Military Medical City, and King Abdullah Bin Abdulaziz University Hospital, employed a modified Delphi consensus methodology, a structured technique designed to distill reliable group judgment from panels of specialists. Between January and March 2026, the team recruited pediatric clinical pharmacists who each had at least two years of clinical experience in pediatric or neonatal care and were actively practicing in Saudi Arabia. Rather than relying on a single survey or a top-down policy document, the Delphi approach iteratively collects, refines, and re-rates expert opinions until a stable consensus emerges, making it particularly well suited to questions where evidence from controlled trials is thin or fragmented.

The study unfolded in two rounds. In the first, the participating experts generated recommendations across predefined domains of medication safety, which the research team then reviewed, refined, and consolidated to remove redundancy and sharpen the wording. In the second round, the same experts rated every consolidated recommendation on a five-point Likert scale, expressing degrees of agreement or disagreement. The researchers set a deliberately demanding bar for consensus: at least 80 percent of the panel had to agree with a recommendation, and no more than 15 percent could disagree, before it was accepted as a validated priority. This dual threshold guards against the common pitfall of consensus studies in which lukewarm majorities are mistaken for genuine expert agreement.

Participation and retention were striking. Nineteen experts completed both rounds, representing a 100 percent retention rate, a figure that lends considerable weight to the results because attrition bias, in which dissenting participants drop out between rounds, is a chronic weakness of Delphi research. The raw output of the first round was substantial: 301 individual recommendations, which the consolidation process distilled into 81 distinct recommendations organized across eight domains. Of those 81, a remarkable 70 achieved the predefined consensus criteria, an approval rate suggesting that the panel shared a coherent vision of what pediatric medication safety in the Kingdom should look like.

The domain-level results were especially revealing. Every single recommendation within four of the eight domains, those covering staff-related measures, protocols and guidelines, medication-related practices, and technology-related interventions, met the consensus threshold. In other words, the experts agreed unanimously at the category level that workforce competence, standardized procedures, careful medication management, and digital health tools are the load-bearing pillars of pediatric drug safety. Domains that did not achieve full consensus still contributed accepted recommendations, but the clean sweep in those four categories signals where the panel saw the least ambiguity and the greatest urgency.

From the pool of accepted recommendations, the researchers identified fifteen top priorities based on the strongest observed consensus: a median rating of 5 on the five-point scale, 94.7 percent agreement, and zero percent disagreement. These priorities read like a checklist of modern pediatric pharmacy practice. They include sustained staff training, antimicrobial stewardship programs to curb the misuse of antibiotics, the standardization of medication concentrations to eliminate dangerous variability in how liquid drugs are prepared, and double-check systems for high-risk medications, a class that in pediatric settings includes drugs such as insulin, anticoagulants, and concentrated electrolytes where a tenfold dosing error can be fatal.

Technology featured prominently among the priorities, reflecting a global shift toward engineered safety systems rather than reliance on human vigilance alone. The panel endorsed electronic prescribing, which eliminates the illegible handwriting and transcription errors of paper orders; barcode medication administration, which verifies at the bedside that the right patient is receiving the right drug at the right dose; smart infusion pumps equipped with dose-error reduction software, which can intercept programming mistakes before medication reaches a child’s bloodstream; and therapeutic drug monitoring, the laboratory-guided measurement of drug levels that allows clinicians to individualize dosing for medicines with narrow therapeutic windows. Improved communication among healthcare providers rounded out the list, an acknowledgment that many pediatric errors originate not in calculation but in the handoffs and verbal exchanges where critical information is lost.

The technical logic behind several of these priorities deserves emphasis. Standardized concentrations address a well-documented hazard: when different units or different pharmacies prepare the same pediatric liquid medication at different strengths, a nurse accustomed to one concentration can inadvertently administer a multiple of the intended dose elsewhere. Antimicrobial stewardship in pediatrics carries a dual imperative, because inappropriate antibiotic use harms the individual child through adverse events and resistance while simultaneously eroding the collective efficacy of the antibiotic arsenal. Double-check systems for high-risk medications operationalize the principle that independent verification by a second qualified practitioner catches errors that a single fatigued mind will miss, and the evidence base for barcode verification and smart pump technology in reducing administration errors has grown steadily over the past two decades.

What distinguishes this study is not merely its list of interventions but its grounding in local clinical reality. Global guidance from bodies such as the World Health Organization, whose medication safety challenge has repeatedly highlighted pediatric patients as a vulnerable group, provides general direction, but implementation always collides with local constraints: staffing levels, formulary availability, existing electronic infrastructure, and cultural patterns of communication. By asking Saudi pediatric clinical pharmacists, the professionals who sit at the intersection of prescribing, dispensing, and monitoring, to generate and rank the recommendations themselves, the researchers produced a priority list that is simultaneously evidence-informed and executable within the Saudi healthcare context. The study received ethical approval from the Institutional Review Board of King Abdullah Bin Abdulaziz University Hospital and was funded through the Princess Nourah bint Abdulrahman University Researchers Supporting Project initiative.

The implications extend beyond the Kingdom’s borders. Many low- and middle-income health systems, and indeed some high-income ones, face the same fundamental challenge: an abundance of safety recommendations and a scarcity of resources, forcing administrators to choose where to invest first. A rigorously derived expert consensus, achieved with complete panel retention and a strict statistical definition of agreement, offers a defensible answer to that triage question. For Saudi Arabia, the fifteen priority recommendations now constitute a ready-made agenda for hospital administrators, policymakers, and pharmacy departments: train the workforce, standardize the concentrations, steward the antibiotics, double-check the dangerous drugs, and deploy the prescribing, barcode, infusion, and monitoring technologies that turn individual diligence into system-level protection. For children, who cannot advocate for their own medication safety and whose developing bodies are least equipped to tolerate error, that agenda cannot arrive soon enough.

Subject of Research: Expert consensus on pediatric medication safety priorities in Saudi Arabia

Article Title: Medication safety priorities for pediatric patients in Saudi Arabia: a Delphi consensus among pediatric clinical pharmacists

Article References: Alshehri, G. H., Khawagi, W. Y., Alshehri, A. A., Alsubaie, R. S., Alrefay, M., Alhumaidi, R., Alawfi, R., Aldhuwayhi, B., Alnakhli, A. M., & Nahari, M. (2026). Medication safety priorities for pediatric patients in Saudi Arabia: a Delphi consensus among pediatric clinical pharmacists. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07755-w

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07755-w

Keywords: medication safety, pediatrics, medication errors, Delphi technique, clinical pharmacy, Saudi Arabia, patient safety, antimicrobial stewardship, electronic prescribing, smart infusion pumps, therapeutic drug monitoring, expert consensus