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Medication errors in a pediatric 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.

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    • "Extensive work has been undertaken to examine the prevalence of medication errors in hospitalised children. For example, in a retrospective review of medication errors documented in standard reporting forms, Ross et al. (2000) found 195 errors over a five-year period (0.51 per 1,000 bed days) across all clinical settings in a UK children's teaching hospital. In a prospective cohort study using an adverse incident reporting scheme, Wilson et al. (1998) found 117 errors over a two-year period (82.9 medication errors per 1,000 bed days) in a paediatric cardiac ward and a paediatric cardiac intensive care unit of a UK combined adult and children's teaching hospital. "
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    • "In pediatrics, weight-based dosing is almost universal, with more frequent prescribing errors than in adults. Error rates for children appear to be inversely related to patient size and weight, with infants in newborn intensive care having the highest rates of error [62] and potential ADEs [15]. In a study of potential ADEs, 13% were found to be secondary to miscalculation [52]. "
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    ABSTRACT: Computerized provider order entry (CPOE) and clinical decision support (CDS) are advocated health care information technologies for improving patient safety through reduction and prevention of medication errors. CPOE and DCS target specific errors in medication processes, particularly in prescribing and ordering. These are of particular importance in pediatrics, because children may be more vulnerable to prescribing errors than adults. Studies of CPOE/CDS performed at academic medical centers have demonstrated their effectiveness in reducing medication process errors in pediatrics, but scant data so far show effects on health outcomes. CPOE/CDS adoption requires significant expertise in health care processes, information technology, and change management. Adoption is a high-cost, high-risk venture with political implications.
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    • "Leape and colleagues [38] found that physicians committed 39% of all detected errors, nurses 38%, and pharmacists 12%. However, using different definitions of errors and different methods of detection may determine the proportion of errors committed by different professionals [19] [27] [31]. "
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