Article

Medication errors in a paediatric teaching hospital in the UK: five years operational experience.

Department of Child Health, University of Glasgow, Royal Hospital for Sick Children, Yorkhill NHS Trust, Glasgow G3 8SJ, UK.
Archives of Disease in Childhood (Impact Factor: 2.91). 01/2001; 83(6):492-7.
Source: PubMed

ABSTRACT In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients.
To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence.
Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions.
Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year.
The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further.

0 Bookmarks
 · 
114 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Since 1999, the problem of patient safety has drawn particular attention, becoming a priority in health care. A "medication error" (ME) is any preventable event occurring at any phase of the pharmacotherapy process (ordering, transcribing, dispensing, administering, and monitoring) that leads to, or can lead to, harm to the patient. Hence, MEs can involve every professional of the clinical team. MEs range from those with severe consequences to those with little or no impact on the patient. Although a high ME rate has been found in neonatal wards, newborn safety issues have not been adequately studied until now. Healthcare professionals working in neonatal wards are particularly susceptible to committing MEs due to the peculiarities of newborn patients and of the neonatal intensive care unit (NICU) environment. Current neonatal prevention strategies for MEs have been borrowed from adult wards, but many factors such as high costs and organizational barriers have hindered their diffusion. In general, two types of strategies have been proposed: the first strategy consists of identifying human factors that result in errors and redesigning the work in the NICU in order to minimize them; the second one suggests to design and implement effective systems for preventing errors or intercepting them before reaching the patient. In the future, prevention strategies for MEs need to be improved and tailored to the special neonatal population and the NICU environment and, at the same time, every effort will have to be made to support their clinical application.
    World journal of clinical pediatrics. 08/2014; 3(3):37-44.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Medication errors (ME) and adverse drug reactions still continue to be the important factors for out- and in-patient treatments. MEs are critical troubles in all hospitalized populations that can increase length of hospital stay, expenses, mortality and morbidity. In many countries, clinical pharmacists have been involved in reducing MEs from years ago. A growing body of evidence suggests that pharmacist interventions have major impact on reducing MEs in pediatric patients, thus improving the quality and efficiency of care provided. This paper presents a literature review on the role of clinical pharmacists in reducing MEs, and underscores the importance of pharmacist-physician-patient collaboration for all patients notably in the pediatric age group.
    Journal of Pharmacy Practice and Research 07/2012; 1(1):10-3.
  • [Show abstract] [Hide abstract]
    ABSTRACT: To systematically examine the research literature to identify which interventions reduce medication errors in pediatric intensive care units.
    Annals of Pharmacotherapy 07/2014; · 2.92 Impact Factor

Full-text (2 Sources)

Download
72 Downloads
Available from
May 30, 2014