Objective: To reduce the risk of digitalis poisoning induced by digoxin in children

so as to ensure the safety of medication. Methods: The tracer methodology was used to track the case of digitalis poisoning in children

the possible risk points were find out

the potential risks in the system or process were analyzed

and corresponding countermeasures were formulated for continuous improvement

and the management effects before and after the tracking were evaluated. Results: Individual tracer activity found that the main risk points of digitalis poisoning in children were drug dosage and combination of drugs. System tracer activity showed that there were risks induced by drug factors

personnel factors and information system factors. Through the implementation of risk control countermeasures

there were no digitalis poisoning in children and off-label instructions in medical orders after the follow-up. After tracer methodology

the monitoring rate and cure rate of therapeutic drug monitoring (TDM) were significantly higher than those before tracer methodology (P<0.05). Conclusion: The incidence of digitalis poisoning in children can be reduced and the medication safety can be ensured through applying tracking methodology for the identification of risk points and implementation of preventive measures by pharmacists