Errors In Infants Research Articles

Refractive errors in infants with retinopathy of prematurity treated using laser or anti-vascular endothelial growth factor monotherapy

Background: Infants treated for retinopathy of prematurity (ROP) could develop visually significant refractive errors. In this study, we report pre-treatment refractive errors in premature infants with treatment-requiring ROP treated using laser or anti-VEGF monotherapy and compare the components of post-treatment refractive error values between the two treatment groups at different follow-up timepoints.
 Methods: In this retrospective cohort study, we analyzed 360 eyes of 181 premature infants with treatment-requiring ROP who were referred to Farabi Eye Hospital, Tehran, Iran between March 2020 and April 2021. Of the 360 eyes, 195 received laser monotherapy (laser treatment group) and 165 received an intravitreal anti-VEGF injection (anti-VEGF therapy group). All included eyes underwent pre- and post-treatment cycloplegic refraction. Cycloplegia was induced for each infant by instilling a mixed eye drop containing 1% tropicamide, 2.5% phenylephrine, and 0.5% tetracaine (in equal volumes) in each eye three times at five-minute intervals. Cycloplegic refraction was performed 30 minutes after the third instillation.
 Results: The mean (standard deviation [SD]) gestational age (GA) and birth weight (BW) of the infants were 29.0 (2.0) weeks and 1241.0 (403.0) g, respectively. The male-to-female ratio in the entire study cohort was 107 (59.1%) / 74 (40.9%), whereas the ratios in the anti-VEGF therapy group and laser treatment group were 47 (56.6%) / 36 (43.4%) and 60 (61.2%) / 38 (38.8%), respectively. The pre-treatment assessment revealed that 218 (60.6%) eyes were hyperopic, 112 (31.1%) were myopic, and 30 (8.3%) were emmetropic. In the anti-VEGF therapy group, 87 (52.7%) eyes were hyperopic, 63 (38.2%) were myopic, and 15 (9.1%) were emmetropic. In the laser treatment group, 131 (67.2%) eyes were hyperopic, 49 (25.1%) were myopic, and 15 (7.7%) were emmetropic. The mean (SD) spherical refractive error and spherical equivalent of refractive error (SEQ) at the 1-week, 1-month, and > 6-month post-treatment follow-up timepoints; the mean cylindrical refractive error at the 3-month post-treatment timepoint; and the mean SEQ at the time of ROP regression were significantly different between the treatment groups (all P < 0.05). The rate of anisometropia increased significantly from 3.4% at baseline to 9.2% at the 6-month post-treatment follow-up timepoint (P < 0.05).
 Conclusions: In this study, the most common pre-treatment refractive status of all included eyes with treatment-requiring ROP and eyes in each treatment group was hyperopia, followed by myopia and emmetropia. At the more than 6-month post-treatment follow-up, cycloplegic refraction revealed that the laser-treated eyes were significantly more hyperopic than the anti-VEGF-treated eyes, a finding similar to the pre-treatment refraction results. Further studies of same cohort with a longer follow-up period and a control group are needed to determine the real-world effect of each treatment modality on the refractive statuses of children treated for ROP.

A fatal yet salvageable inborn error – leukocyte adhesion deficiency

Leukocyte adhesion deficiency (LAD) Type 1 is a rare inborn error in infants characterized by delayed umbilical cord detachment, non-healing ulcers, and leukocytosis. Initially, knowledge of LAD was limited to the impairment of granulocyte function due to the scarcity of cases. However, as more and more cases are being reported, the knowledge of the bio-physiology of white blood cells, platelets, and various intercellular reactivity and signaling provides a new perception of this disease. We present a 17-day-old female child who presented with complaints of fever and redness in the perianal region and popliteal fossa. Investigations showed leukocytosis in blood and cerebrospinal fluid (CSF), raised C-Reactive Protein (CRP), and Pseudomonas-positive blood and CSF culture. Flow cytometry revealed the absence of CD18, CD11a, and CD11c. Aggressive antimicrobial agents were started; however, the baby died on day 30 of life. In this report, we emphasize the essential investigations needed for early diagnosis and effective precautions through which we can decrease the fatality rate of this rare disorder.

Beyond Infant’s Looking: The Neural Basis for Infant Prediction Errors

Contemporary conceptualizations on infant cognitive development focus on predictive processes; the basic idea is that the brain continuously creates predictions about what is expected and that the divergence between predicted and actual perceived data yields a prediction error. This prediction error updates the model from which the predictions are generated and therefore is a basic mechanism for learning and adaptation to the dynamics of the ever-changing environment. In this article, we review the types of available empirical evidence supporting the idea that predictive processes can be found in infancy, especially emphasizing the contribution of electrophysiology as a potential method for testing the similarity of the brain mechanisms for processing prediction errors in infants to those of adults. In infants, as with older children, adolescents, and adults, predictions involve synchronization bursts of middle-central theta reflecting brain activity in the anterior cingulate cortex. We discuss how early in development such brain mechanisms develop and open questions that still remain to be empirically investigated.

Analysis of an Intervention for Emergency Medical Services Personnel to Reduce Epinephrine Dosing Errors in Infants

This quality improvement study investigates whether a simulation-driven emergency medical services protocol of using a 1-mL syringe to administer small epinephrine doses could reduce dosing errors in infants.

The impact of errors in infant development: Falling like a baby.

What is the role of errors in infants' acquisition of basic skills such as walking, skills that require immense amounts of practice to become flexible and generative? Do infants change their behaviors based on negative feedback from errors, as suggested by "reinforcement learning" in artificial intelligence, or do errors go largely unmarked so that learning relies on positive feedback? We used falling as a model system to examine the impact of errors in infant development. We examined fall severity based on parent reports of prior falls and videos of 563 falls incurred by 138 13- to 19-month-old infants during free play in a laboratory playroom. Parent reports of notable falls were limited to 33% of infants and medical attention was limited to 2% of infants. Video-recorded falls were typically low-impact events. After falling during free play in the laboratory, infants rarely fussed (4% of falls), caregivers rarely showed concern (8% of falls), and infants were back at play within seconds. Impact forces were mitigated by infants' effective reactive behaviors, quick arrest of the fall before torso or head impact, and small body size. Moreover, falling did not alter infants' subsequent behavior. Infants were not deterred from locomotion or from interacting with the objects and elevations implicated in their falls. We propose that a system that discounts the impact of errors in early stages of development encourages infants to practice basic skills such as walking to the point of mastery.

Homecare and Healthcare Utilization Errors Post-Neonatal Intensive Care Unit Discharge.

Background:High-risk infants transitioning from the neonatal intensive care unit (NICU) to home represent a vulnerable population, given their complex care requirements. Little is known about errors during this period.Purpose:Identify and describe homecare and healthcare utilization errors in high-risk infants following NICU discharge.Methods:This was a prospective observational cohort study of homecare (feeding, medication, and equipment) and healthcare utilization (appointment) errors in infants discharged from a regional NICU between 2011 and 2015. Chi-square test and Wilcoxon rank-sum test were used to compare infant and maternal demographics between infants with and without errors.Results:A total of 363 errors were identified in 241 infants during 635 home visits. The median number of visits was 2. No significance was found between infant and maternal demographics in those with or without errors.Implications of Practice:High-risk infants have complex care needs and can benefit from regular follow-up services. Home visits provide an opportunity to identify, intervene, and resolve homecare and healthcare utilization errors.Implications of Research:Further research is needed to evaluate the prevalence and cause of homecare errors in high-risk infants and how healthcare resources and infant health outcomes are affected by those errors. Preventive measures and mitigating interventions that best address homecare errors require further development and subsequent description.

Early natural history of moderate refractive errors in infants

The purpose of this study was to investigate the early natural history of children diagnosed with refractive errors before 1 year of age.

Propranolol and periocular capillary hemangiomas: assessment of refractive effect.

To assess the effects of systemic propranolol on refractive error in infants with periocular capillary hemangiomas. A single-center study of consecutive patients with capillary hemangiomas treated with systemic propranolol. Refractive data were analyzed using Long's matrix formalism and the methods of Harris and Kaye. Seventeen patients were included. At 6 months postoperatively, hemangioma size reduced from 3,214 to 1,806 mm(3) (standard deviation: 4,122 to 2,441). Mean refractive error in the affected eye significantly reduced: -1.25/0.38 × 36 (95% confidence intervals: -5.08/1.20 × 90 to 1.64/1.43 × 180, P = .048) with a smaller change (P = .06) in the unaffected eye of -1.01/+0.31 × 3.16 (95% confidence intervals: -4.02/+1.12 × 180 to +1.49/+0.51 × 90). Propranolol produced a clinically significant reduction in the infants' refractive error and anisometropia. The reduction in the total refractive error and anisometropia has not been evident in previous analyses, which have concentrated on the change in the "cylinder" as the principal outcome measure.

Utility of an open field Shack-Hartmann aberrometer for measurement of refractive error in infants and young children

To assess the utility of an open-field Shack-Hartmann aberrometer for measurement of refractive error without cycloplegia in infants and young children. Data included 2698 subject encounters with Native American infants and children aged 6 months to <8 years. We attempted right eye measurements without cycloplegia using the pediatric wavefront evaluator (PeWE) on all participants while they viewed near (50 cm) and distant (2 m) fixation targets. Cycloplegic autorefraction (Rmax [Nikon Retinomax K-plus2]) measurements were obtained for children aged ≥ 3 years. The success rates of noncycloplegic PeWE measurement for near (70%) and distant targets (56%) significantly improved with age. Significant differences in mean spherical equivalent (M) across near versus distant fixation target conditions were consistent with the difference in accommodative demand. Differences in astigmatism measurements for near versus distant target conditions were not clinically significant. Noncycloplegic PeWE and cycloplegic Rmax measurements of M and astigmatism were strongly correlated. Mean noncycloplegic PeWE M was significantly more myopic or less hyperopic and astigmatism measurements tended to be greater in magnitude compared with cycloplegic Rmax. The PeWE tended to overestimate myopia and underestimate hyperopia when cycloplegia was not used. The PeWE is useful for measuring accommodation and astigmatism.

Intravitreal Bevacizumab for Retinopathy of Prematurity: Refractive Error Results

To evaluate refractive error in infants who underwent intravitreal bevacizumab injection for treatment of threshold retinopathy of prematurity (ROP). Retrospective nonrandomized interventional comparative study. The study group included all infants who consecutively received a single intravitreal bevacizumab (0.375mg or 0.625mg) injection for therapy of threshold ROP in fundus zone I or zone II. The control group included infants who had previously undergone retinal argon laser therapy of ROP. The follow-up examination included refractometry under cycloplegic conditions. The study group included 12 children (23 eyes; mean birth weight: 622 ± 153 g; gestational age: 25.2 ± 1.6weeks) and the control group included 13 children (26 eyes; birth weight: 717 ± 197 g; gestational age: 25.3 ± 1.8weeks). Both groups did not differ significantly in birth age and weight and follow-up. At the end of follow-up at 11.4 ± 2.3months after birth, refractive error was less myopic in the study group than in the control group (-1.04 ± 4.24 diopters [median: 0 diopters] vs-4.41 ± 5.50 diopters [median:-5.50 diopters]; P= .02). Prevalence of moderate myopia (17% ± 8% vs 54% ± 10%; P= .02; OR: 0.18 [95% CI: 0.05, 0.68]) and high myopia (9% ± 6% vs 42% ± 10%; P= .01; OR: 0.13 [95% CI: 0.03, 0.67]) was significantly lower in the bevacizumab group. Refractive astigmatism was significantly lower in the study group (-1.0 ± 1.04 diopters vs 1.82 ± 1.41 diopters; P= .03). In multivariate analysis, myopic refractive error and astigmatism were significantly associated with laser therapy vs bevacizumab therapy (P=.04 and P= .02, respectively). In a 1-year follow-up, a single intravitreal bevacizumab injection as compared to conventional retinal laser coagulation was helpful for therapy of ROP and led to less myopization and less astigmatism.

Pain Panacea for Opiophobia in Infants?

INTRAVENOUS ACETAMINOPHEN (PARACETAMOL) IS SUGgested for use as an opioid-sparing analgesic for children requiring surgery or emergency care, despite limited data on its efficacy and toxicity in infants and children. In this issue of JAMA, the randomized trial by Ceelie and colleagues addresses this evidence gap by showing clinically significant reductions in morphine use among neonates or infants receiving postoperative analgesia. Among patients randomized to receive acetaminophen (n=33) or morphine (n=38) postoperatively, the cumulative morphine dose during the first 48 hours following surgery was 121 g/kg (interquartile range, 99-264) vs 357 g/kg (interquartile range, 220-605), respectively—a 66% relative reduction between groups (P .001). There were no differences in the number of patients requiring morphine rescue doses or in pain scores. These findings merit consideration because of the careful study design, well-matched study groups, and the magnitude of effects observed. However, in addition to the limitations of small sample size, single-center study site, and lack of safety data, these findings also should be interpreted in light of several other considerations. First, given the brief duration of exposure to morphine (48-72 hours) in the trial, it is unlikely that patients in the morphine group developed opioid tolerance, although opioidinduced hyperalgesia could have increased their analgesic requirements. Careful clinical evaluations can differentiate opioid-induced hyperalgesia from opioid tolerance, although standardized clinical tests or biomarkers for opioidinduced hyperalgesia are currently unavailable for this age group. It is possible that some patients in the morphine group may have developed opioid-induced hyperalgesia, partly explaining the wide range of morphine requirements in this group. Another possibility is the accumulation of morphine3-glucuronide, a metabolic product formed preferentially in infants and associated with behavioral excitability and hyperalgesia. These effects were less likely in the group receiving intravenous acetaminophen, perhaps accounting for some of its opioid-sparing effects. Second, synergism between morphine and acetaminophen cannot be ruled out, because all patients received morphine (100 g/kg) before leaving the operating room. The mechanism(s) of acetaminophen analgesia are currently unclear, but several mechanisms could potentiate opioid analgesia. Oral acetaminophen preparations are frequently combined with opioids. However, a randomized trial studying the interactions between intravenous morphine and acetaminophen in 90 adult postoperative patients found additive but not synergistic effects (clinicaltrials.gov Identifier: NCT1366313). In the study by Ceelie et al, some findings suggest that acetaminophen may have been more effective in older infants. In stratified analysis, the cumulative morphine dose in the acetaminophen group compared with the morphine group was 49% lower among neonates aged 0 through 10 days (median dose, 111 g/kg per 48 hours vs 218 g/kg per 48 hours, respectively) and was 73% lower among infants aged 11 through 365 days (median dose, 152 g/kg per 48 hours vs 553 g/kg per 48 hours). For a study designed to investigate the efficacy of acetaminophen, it is arguable that collapsing the age-related strata should have been based on the pharmacokinetics of acetaminophen rather than morphine. Nevertheless, reporting data on morphine dose reductions according to the age-group strata originally designed in this study will be of interest for clinicians. Third, although the age distribution of opioid-related adverse effects in this study population was not reported, an age-related susceptibility to opioid adverse effects is well known with regard to respiratory depression and possibly hypotension. The study by Ceelie et al was designed to focus on the adverse effects of opioids, whereas the toxicity or possible adverse effects of acetaminophen were not evaluated. Hepatic toxicity following intravenous acetaminophen is not uncommon and has been reported following 10-fold dosing errors in infants but also can occur after therapeutic oral doses. Other possible adverse effects include systemic anaphylaxis or localized effects and pain at the site of injection (in one study, this occurred in 15% of patients receiving acetaminophen and in 33% of those receiving propacetamol). However, given the dose and time of exposure in this study, those adverse effects would be unlikely.

Observed Human Actions, and Not Mechanical Actions, Induce Searching Errors in Infants

Recent neurophysiological studies have shown that several human brain regions involved in executing actions are activated by merely observing such actions via a human, and not by a mechanical hand. At a behavioral level, observing a human’s movements, but not those of a robot, significantly interferes with ongoing executed movements. However, it is unclear whether the biological tuning in the observation/execution matching system are functional during infancy. The present study examines whether a human’s actions, and not a mechanical action, influence infants’ execution of the same actions due to the observation/execution matching system. Twelve-month-old infants were given a searching task. In the tasks, infants observed an object hidden at location A, after which either a human hand (human condition) or a mechanical one (mechanical condition) searched the object correctly. Next, the object was hidden at location B and infants were allowed to search the object. We examined whether infants searched the object at location B correctly. The results revealed that infants in the human condition were more likely to search location A than those in the mechanical condition. Moreover, the results suggested that infants’ searching behaviors were affected by their observations of the same actions by a human, but not a mechanical hand. Thus, it may be concluded that the observation/execution matching system may be biologically tuned during infancy.

Accommodative lag and refractive error in infants and toddlers

To measure accommodative performance as a function of refractive error in very young children. This was a prospective study of accommodation lag in multiethnic typically developing children ages 5 to 24 months. Accommodation lag was measured by means of a modified bell retinoscopy technique. Refraction was measured by cycloplegic retinoscopy, and right and left eye results were averaged. The study compared accommodative performance to cycloplegic spherical equivalent and astigmatic refractive error. Analysis of data from 189 of 203 subjects revealed that larger lags and lower gain of the accommodative response were more common in younger children, although most children of all ages accommodated well, with 95% having lags <1.25 D. Larger accommodation lags were associated with greater spherical equivalent refractive error, although only with hyperopia ≥4.0 D were lags ≥1.25 D observed in a majority of children. Larger lags in the more hyperopic meridian were seen with increasing hyperopic with-the-rule astigmatism, but lag in the more hyperopic meridian varied little with the amount of myopic or mixed astigmatism. Most 5- to 24-month-old children accommodate well over a range of moderate hyperopic refractive errors, but hyperopia ≥4.0 D is rarely associated with normal accommodative performance. Hyperopic and mixed or myopic astigmatic children show different patterns of accommodation, which may explain the patterns of visual acuity deficits seen in these children.

Risk Factors Associated with Childhood Strabismus: The Multi-Ethnic Pediatric Eye Disease and Baltimore Pediatric Eye Disease Studies

To investigate risk factors associated with esotropia or exotropia in infants and young children. Population-based cross-sectional prevalence study. Population-based samples of 9970 children 6 to 72 months of age from California and Maryland. Participants were preschool African-American, Hispanic, and non-Hispanic white children participating in the Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Eye Disease Study. Data were obtained by parental interview and ocular examination. Odd ratios and 95% confidence intervals were calculated to evaluate the association of demographic, behavioral, and clinical risk factors with esotropia and exotropia. Odds ratios (ORs) for various risk factors associated with esotropia or exotropia diagnosis based on cover testing. In multivariate logistic regression analysis, esotropia was associated independently with prematurity, maternal smoking during pregnancy, older preschool age (48-72 months), anisometropia, and hyperopia. There was a severity-dependent association of hyperopia with the prevalence of esotropia, with ORs increasing from 6.4 for 2.00 diopters (D) to less than 3.00 D of hyperopia, to 122.0 for 5.00 D or more of hyperopia. Exotropia was associated with prematurity, maternal smoking during pregnancy, family history of strabismus, female sex, astigmatism (OR, 2.5 for 1.50 to <2.50 D of astigmatism, and 5.9 for ≥2.5 D of astigmatism), and anisoastigmatism in the J0 component (OR, ≥2 for J0 anisoastigmatism of ≥0.25 D). Prematurity and maternal smoking during pregnancy are associated with a higher risk of having esotropia and exotropia. Refractive error is associated in a severity-dependent manner to the prevalence of esotropia and exotropia. Because refractive error is correctable, these risk associations should be considered when developing guidelines for the screening and management of refractive error in infants and young children. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Optimized temperature and deadspace correction improve analysis of multiple breath washout measurements by ultrasonic flowmeter in infants

Assessment of lung volume (FRC) and ventilation inhomogeneities with ultrasonic flowmeter and multiple breath washout (MBW) has been used to provide important information about lung disease in infants. Sub-optimal adjustment of the mainstream molar mass (MM) signal for temperature and external deadspace may lead to analysis errors in infants with critically small tidal volume changes during breathing. We measured expiratory temperature in human infants at 5 weeks of age and examined the influence of temperature and deadspace changes on FRC results with computer simulation modeling. A new analysis method with optimized temperature and deadspace settings was then derived, tested for robustness to analysis errors and compared with the previously used analysis methods. Temperature in the facemask was higher and variations of deadspace volumes larger than previously assumed. Both showed considerable impact upon FRC and LCI results with high variability when obtained with the previously used analysis model. Using the measured temperature we optimized model parameters and tested a newly derived analysis method, which was found to be more robust to variations in deadspace. Comparison between both analysis methods showed systematic differences and a wide scatter. Corrected deadspace and more realistic temperature assumptions improved the stability of the analysis of MM measurements obtained by ultrasonic flowmeter in infants. This new analysis method using the only currently available commercial ultrasonic flowmeter in infants may help to improve stability of the analysis and further facilitate assessment of lung volume and ventilation inhomogeneities in infants.

Evidence-based spectacle prescribing for infants and children

Prescribing for refractive errors in infants and young children often presents a greater challenge to the optometrist than in the case of older children and adults. However, spectacle prescribing takes on a very important role in this age group since it can impact visual development. On the one hand, spectacle treatment when properly prescribed can reduce the risk of strabismus and amblyopia and enhance visual development. However, on the other hand, overly aggressive spectacle treatment may impair self-correcting processes (emmetropization) serving to reduce refractive error in the early years of life. Proper prescribing for infants and children must be rooted in an evidence-based approach. This article identifies the current evidence from basic research in ocular development as well as the results from clinical trials pertaining to the outcomes of early spectacle interventions. From this evidence, age specific guidelines are developed.

Evaluation of drug utilization and prescribing errors in infants: A primary care prescription-based study

The purpose of this study is to evaluate the drug utilization trends and to describe the prevalence and type of medication-related prescribing errors in infants treated at primary care health centers in Bahrain. Prescriptions issued for infants were collected over a 2-week period in May 2004 from 20 health centers. Prescribing errors were classified as omission (minor and major), commission (incorrect information) and integration errors. Medications were classified according to the British National Formulary. In infants with a mean age of 6.5 months (±3.1) drugs per prescription were 2.52 (±1.1). Paracetamol and sodium chloride nasal drops were the topmost prescribed systemic and topical drugs, respectively. In 2282 prescriptions, 2066 (90.5%) were with omission (major), commission, and integration errors. In 54.1% of prescriptions with omission errors, length of therapy was not specified in 27.7%, and in 12.8% the dosage form was not stated. In 43.5% of prescriptions with errors of commission, dosing frequency (20.8%) and dose/strength (17.7%)—related errors were most common. Errors of integration such as potential drug–drug interaction comprised 2.4% of all prescribing errors. The proportion of drugs prescribed irrationally were: contraindicated medications, notably chlorpheniramine, promethazine, and corticosteroids (16.1%); medications prescribed on a p.r.n. basis (13.3%); missed information regarding strength of medications (2.8%); medications prescribed over extended periods (2.7%); low dosing frequency (2.6%); supratherapeutic doses (2.3%); excessive dosing frequency (0.8%). Irrational drug therapy in infants, with prescribing errors were apparent in primary care practice, which may be related to a lack of drug information, pharmacovigilance programme, and nonadherence to basic principles of prescribing. Establishing a national drug policy and pharmacovigilance programme for promoting rational drug use are to be considered. There is also a need to evaluate the effectiveness of interventions by measuring the outcomes.

Rational Use of Antimicrobials in Infants in Primary Care of Bahrain

This nationwide prescription-based study was undertaken to evaluate antimicrobial prescribing for infants, and to identify prescribing errors in infants in 20 primary care health centres of Bahrain. Data was collected on a daily basis by pharmacists in May 2004. Antimicrobials ranked the 5th most common drugs prescribed in infants; beta-lactams, notably amoxycillin and cephalexin, comprised 81.6% of overall prescribed antimicrobials. Antimicrobials were prescribed to approximately one out of four infants (23.8%), prescribed more often to infants aged 9-12 months of age. Approximately one-fifth (22%) of infants received antimicrobials at subtherapeutic daily doses. The prescribing errors were related to dosage (39.2%), strength/doses (26.4%), frequency of dosing (19.2%), and duration of therapy (4.5%). Antimicrobial dosage prescribed in relation to infants' age revealed a positive correlation for amoxycillin (r = 0.264; p < 0.0001), cephalexin (r = 0.223; p = 0.029), erythromycin (r = 0.127; p = 0.284), and a negative correlation for metronidazole (r = -0.183; p = 0.415). Overt use of antimicrobials in infants, and prescription-writing errors (in dosages and frequency of dosing) were common in primary care. Dosage adjustment in relation to developmental stages of infants has received inadequate attention. Effective strategies to improve prescription writing skills are urgently required.

Refractive Errors in Infants

Refractive Errors in Infants

Drug administration errors in infants: don't blame individuals, fix the system

Drug administration errors in infants: don't blame individuals, fix the system