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This study examined the individual and temporal factors that explain whether the medication cardex agrees with a physician's pediatric medication order. After controlling for several potentially confounding factors, it was found that, among other things, pediatric intensive care unit cardexes were 62% less likely to agree with the physician order than cardexes from other units. Cardexes for "stat" orders were twice as likely to agree with the physician order. These data support the possibility that "low-tech" changes in the process of providing care can improve the likelihood that the medication order will agree with the cardex and, as a result, reduce the likelihood of medication errors.

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