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.

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    • "Errors were due to use of wrong dose, route, and dosage. Literature reveals that errors concerning dose, route and time are the top medication errors in pediatric settings[1,2,7,8]. Besides adversely affecting the well-being of the pediatric patients, potentially these errors can result in frustrations, powerlessness, and anger among patients and their family members. "

    Full-text · Article · Jan 2016
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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. "

    Full-text · Article · Feb 2014 · International journal of nursing studies
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    • "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). "
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