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: 2.9). 01/2001; 83(6):492-7.
Source: PubMed


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.

Download full-text


Available from: James Paton,
  • Source
    • "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. "

    International journal of nursing studies 02/2014; 51(10). DOI:10.1016/j.ijnurstu.2014.02.008 · 2.90 Impact Factor
  • Source
    • "Although there are abundant advantages and ethical bases in elaboration and reports of nurses’ errors, it is very difficult to obtain accurate statistics of medication errors due to nurses’ protection against punishment, managerial laws regarding detection of errors, absence of an appropriate reporting and recording system, and shortage of information (21–23). One study conducted in England reported a medication error rate of about 15% and nurses were responsible for 56% of these errors (24). The study by Simpson et al. showed that 71% of errors were due to imperfect prescriptions and 29% were due to dose calculation of medications, and the most prevalent types of errors were no administration, inappropriate medication, and medication at inappropriate time (25). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Patient safety is one of the main concepts in the field of healthcare provision and a major component of health services quality. One of the important stages in promotion of the safety level of patients is identification of medication errors and their causes. Medical errors such as medication errors are the most prevalent errors that threaten health and are a global problem. Execution of medication orders is an important part of the treatment and care process and is regarded as the main part of the nurses’ performance. The purpose of this study was to explore the medication error reporting rate, error types and their causes among nurses in the emergency department. In this descriptive study, 94 nurses of the emergency department of Imam Khomeini Hospital Complex were selected based on census in 2010–2011. Data collection tool was a researcher-made questionnaire consisting of two parts: demographic information, and types and causes of medication errors. After confirming content-face validity, reliability of the questionnaire was determined to be 0.91 using Cronbach’s alpha test. Data analyses were performed by descriptive statistics and inferential statistics. SPSS-16 software was used in this study and P values less than 0.05 were considered significant. The mean age of the nurses was 27.7 ± 3.4 years, and their working experience was 7.3 ± 3.4 years. Of participants 46.8% had committed medication errors in the past year, and the majority (69.04%) had committed the errors only once. Thirty two nurses (72.7%) had not reported medication errors to head nurses or the nursing office. The most prevalent types of medication errors were related to infusion rates (33.3%) and administering two doses of medicine instead of one (23.8%). The most important causes of medication errors were shortage of nurses (47.6%) and lack of sufficient pharmacological information (30.9%). This study showed that the risk of medication errors among nurses is high and medication errors are a major problem of nursing in the emergency department. We recommend increasing the number of nurses, adjusting the workload of the nursing staff in the emergency department, retraining courses to improve the staff’s pharmacological information, modification of the education process, encouraging nurses to report medical errors and encouraging hospital managers to respond to errors in a constructive manner in order to enhance patient safety
    Journal of Medical Ethics and History of Medicine 11/2013; 6:11.
    • "They also found that the introduction of a strategy for double checking the drugs at the hospital pharmacy location could reduce the number of medication errors by 3.8 units. They also changed the error-reporting form to a less punitive form, which could increase the error-reporting rate by 10%.[24] Although the Ross et al. study is more limited than the current study, they could increase the error-reporting rate. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P < 0.001) and the error-reporting rate was higher (P < 0.007) compared to before the intervention and also in comparison to the nurses of the control hospital. Based on the results of this study and taking into account the high-risk nature of the medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.
    Iranian journal of nursing and midwifery research 03/2013; 18(5):371-377.
Show more