Despite recent advances in development and regulation of medicines for children, unavoidable factors specific to the care of this age group will always make prescribing for infants and children challenging. These factors (see Figure 12.1) include: • the changes in anatomy and physiology that occur during child development that impact on drug pharmacokinetics and pharmacodynamics. • the general lack of research on drug safety and efficacy in children due to practical and ethical reasons • the need to individualise drug dosage based on parameters such as the child’s age, weight or surface area • the limited availability of medicinal products specifically formulated for children • the vagaries of administering medicines to infants and children • the general difficulties of communicating with children • the challenge of diagnosing and recognising adverse reactions in children • the higher risk for medication error in paediatrics • the frequency of off-label prescribing in paediatrics and associated medicolegal issues, and • recognition that treatment of infants and children involves managing their parents and/or carers as well.

Surgical patients undergo multiple transitions of care, from home to the operating room, to a recovery unit to a ward, and so on. Each transition poses a risk of medication error if the current medications are not reconciled or managed appropriately in the new phase of care. Home medications may be suspended, stopped, substituted for, or need to be continued, often in the face of changing preoperative guidelines. Admission and discharge medication reconciliations are at high risk for inaccuracies and for mis-information for the patient as well as the patient's primary provider. Intraoperative medication management is largely but not exclusively, under the control of the anesthesiologist, who serves as the sole agent for the prescription, dispensing, preparation, administration, documentation and monitoring of the anesthetic medications. Common errors include syringe or vial swaps, omissions (e.g., no redosing of antibiotics), wrong route, wrong dose, and even wrong choice of medication. Medication errors occur in approximately every 2 anesthetics, most are of little to no harm, but each has the potential for significant injury. Medication errors also can be made by a surgeon or OR nurse; communication failures between care team members often contribute.