Introduction: In the case of pediatric patients, the likelihood of medication errors is high due to factors such as incorrect
drug dosage, insufficient pediatric medication information, and operation of medication infusion pumps. When medication
errors occur, limited communication and the immature metabolism and excretion functions of children can lead to
significant harm. Particularly for pediatric patients with blood tumors, the vast and complex information regarding the
administration of anticancer drugs and transplantation-related medications increases the probability of medication errors
compared to other pediatric patients. The higher frequency of administering high-risk drugs, such as anticancer agents,
also amplifies the severity of harm in case of medication errors. Therefore, our team aimed to provide safe medication
nursing for pediatric blood tumor patients by analyzing the root causes of medication errors and planning improvement
activities.
Methods:  We analyzed the causes of medication errors in pediatric blood tumor patients from the perspectives of
healthcare professionals, patients, information, and environment.
Conducted campaigns for improving patient identification awareness, including attaching 'patient bracelets' and
'medication label' stickers to the mobile medication system, along with competency assessments. Activities included pre-
and post-surveying patient identification awareness, re-education through pre-and post-surveys, on-site monitoring,
monitoring mobile medication system usage rates, rewarding outstanding users, conducting ward conferences, providing
specialized oncology education, creating and distributing FAQ materials, conducting ad-hoc education based on requests
from individuals or wards, updating anticancer sheets, and monitoring medication label attachment rates for continuous
infusion pump use.
Results: The medication error rate decreased by 66.6%, and correct awareness of mobile medication system usage
increased by 2%. The mobile medication system usage rate surpassed 90%. A total of 57 anticancer sheets were
updated, 10 pediatric blood tumor patient medication FAQ materials were created, and 82 individuals completed
education on pediatric blood tumor patient care. The medication label attachment rate for continuous infusion pump use
exceeded 80%.