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doi:10.1111/jpc.12412

ORIGINAL ARTICLE

Medication errors in hospitalised children Elizabeth Manias,1 Sharon Kinney,1 Noel Cranswick2 and Allison Williams3 1 Melbourne School of Health Sciences, The University of Melbourne, 2Department of Clinical Pharmacology, Royal Children’s Hospital, Parkville and 3School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia

Aim: This study aims to explore the characteristics of reported medication errors occurring among children in an Australian children’s hospital, and to examine the types, causes and contributing factors of medication errors. Methods: A retrospective clinical audit was undertaken of medication errors reported to an online incident facility at an Australian children’s hospital over a 4-year period. Results: A total of 2753 medication errors were reported over the 4-year period, with an overall medication error rate of 0.31% per combined admission and presentation, or 6.58 medication errors per 1000 bed days. The two most common severity outcomes were: the medication error occurred before it reached the child (n = 749, 27.2%); and the medication error reached the child who required monitoring to confirm that it resulted in no harm (n = 1519, 55.2%). Common types of medication errors included overdose (n = 579, 21.0%) and dose omission (n = 341, 12.4%). The most common cause relating to communication involved misreading or not reading medication orders (n = 804, 29.2%). Key contributing factors involved communication relating to children’s transfer across different clinical settings (n = 929, 33.7%) and the lack of following policies and procedures (n = 617, 22.4%). More than half of the reports (72.5%) were made by nurses. Conclusion: Future research should focus on implementing and evaluating strategies aimed at reducing medication errors relating to analgesics, anti-infectives, cardiovascular agents, fluids and electrolytes and anticlotting agents, as they are consistently represented in the types of medication errors that occur. Greater attention needs to be placed on supporting health professionals in managing these medications. Key words:

clinical audit; hospital communication systems; hospitalised child; medication errors.

What is already known on this topic

What this paper adds

1 Children are particularly susceptible to experiencing a medication error. They vary in weight, body surface area, and organ maturity, which can affect their ability to metabolise and excrete medications effectively. 2 Medication error rates in hospitalised children vary considerably due to the diverse environments in which studies are conducted and various data collection methods used. 3 Leading causes of paediatric medication errors have been shown to be performance deficits, procedures or protocols not being followed, knowledge deficits, calculation errors, and lack of communication.

1 All reported medication errors were associated with a cause relating to communication in some way; the most common causes relating to communication involved misreading or not reading medication orders and problems with bedside communication. 2 The most common contributing factors involved communication relating to patient movements across different clinical settings and the lack of following policies and procedures. 3 In over half of all reported cases, the medication error reached the child who required monitoring to confirm that it resulted in no harm.

Safe and effective medication management in children ensures a healthy state of wellbeing and has economic and social benefits.1,2 An important aspect of safe and effective medication management is to examine medication errors and their characteristics, with the aim of identifying and implementing preventative strategies.3,4 Children are particularly susceptible to Correspondence: Dr Elizabeth Manias, Melbourne School of Health Sciences, Level 6, Alan Gilbert Building, 161 Barry Street, The University of Melbourne, Parkville, Vic. 3010, Australia. Fax: +613 8344 5391; email: [email protected] Conflict of interest: The authors declare that they have no known conflicts of interest in relation to this paper. Accepted for publication 6 June 2013.

experiencing a medication error.5 They vary in weight, body surface area, and organ maturity, which can affect their ability to metabolise and excrete medications effectively. In comparing adult and paediatric medication error rates, between 3.2 and 323.0 medication errors/100 admissions have been found in adults, while between 2.4 and 44.3 medication errors/100 admissions occur in children.6 Improper dose or quantity has been shown to be the most common type of medication error in children, while the use of wrong medication has been shown to be the most common type of error in adults.7 Medication error rates in hospitalised children vary considerably due to the diverse environments in which studies are conducted and various data collection methods used. Rates have varied between 0.15 and 17.2 medication errors per 100 admissions.8–10

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Chart reviews have revealed differences between 5.9 and 24 medication errors per 100 orders.11,12 In a retrospective analysis of 43 287 records submitted to the MedMARx database in the US,7 paediatric patients were involved in 1969 (5%) medication errors, and 102 (5%) were found to be harmful. Common types of medication errors were dose omission (27%) and improper dose or quantity (25%). Other investigators have found that common types of medication errors include wrong medications, wrong patients, incorrect routes of administration, incorrect frequencies of administration, medications given to children with known allergies, drug interactions, intravenous incompatibilities, and incorrect rates of intravenous administration.5,8,13,14 Leading causes of paediatric medication errors are performance deficits, procedures or protocols not being followed, knowledge deficits, calculation errors, and lack of communication.15 Little research has been undertaken in Australia about the characteristics of medication errors in hospitalised children.16 In an audit of medication charts in an Australian paediatric department, Dawson et al.17 found 52 major errors in 212 (24.5%) medication charts. The most common types of errors were incorrect dose (12.3%), administration frequency (5.7%), administration route (5.2%), and medication name or formulation (1.4%). Titchen et al.,18 who examined incident reports and patient discharge codings, detected 25 adverse drug reactions in children aged from 4 months to 22 years relating to non-steroidal anti-inflammatory drug and paracetamol use, of which 36% were considered to be definitely avoidable. There is a dearth of recent Australian research examining medication errors in hospitalised children. In particular, little information exists about the nature and incidence of medication errors in various inpatient and outpatient paediatric environments and the contributing factors associated with medication errors in hospitalised children. The aims of this study were to explore characteristics of reported medication errors occurring among children in an Australian children’s hospital, and to examine the types, causes, and contributing factors of medication errors.

Results

Materials and Methods A retrospective clinical audit was undertaken of medication errors submitted to an online voluntary incident reporting system at an Australian tertiary children’s hospital, comprising 334 beds. The hospital has a diverse range of clinical and tertiary care services, and health promotion and prevention programs for infants, children and young people. It contains an emergency department, neonatal intensive care, paediatric intensive care and hospital-in-the-home services. For this study, a medication error was defined as any preventable event that may cause or lead to inappropriate medication use or patient harm.19 Medication errors can occur at any stage of the medication management process, including supplying, prescription, documentation, preparation, and administration. A hospital-wide medication error reporting policy was applied to all areas of the hospital and health professionals were strongly encouraged to document all medication errors that they encountered on the online system. The ethics committee of the hospital approved the conduct of the study. 72

Eligible cases for inclusion were all medication errors reported to the hospital from the 1st of July, 2006 to the 30th of June, 2010. All documented medication errors occurring in children admitted to any clinical setting during the study period, were included. Health professionals usually provided comprehensive descriptions about medication errors in the form of free-text. Medical records of children were also accessed to obtain further clarification of the medication errors that occurred. Demographic data collected included the child’s age and gender. Data on all medication errors were collected and examined consecutively for the 48-month study period. Data collection involved utilisation of the Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) tool.19 This tool provides a standardised, systematic and comprehensive approach in recording, tracking and evaluating medication errors. The tool is divided into seven components, comprising the medication error event, patient outcome, description of the medication involved, personnel involved, type of medication error, causes, and contributing factors. Medication error reports were carefully read, and classified according to the categories designated on the tool. Causes were determined by reading the free text description for each medication error and assigning causes within four subcategories in the NCC MERP tool: communication; name confusion; labelling; and human factors. Accuracy of data categorisation using the NCC MERP tool was independently checked by two authors in a random sample of 59 cases, and 100% agreement was obtained. Data were analysed using the Statistical Package for the Social Sciences (SPSS) (Version 19, Chicago). Descriptive data analyses were undertaken, including frequency counts and percentages for all outcome variables of interest, including types of medication, causes and contributing factors. Means and standard deviations were calculated for continuous variables that were normally distributed, while medians and inter-quartile ranges were calculated for continuous variables that were not normally disturbed.

A total of 2753 medication errors were reported during the 4-year period. Over this period, there were 140 211 inpatient admissions and 749 222 outpatient and emergency department presentations, and 418 216 bed days. Thus, there was an overall medication error rate of 1.96% per admissions, 0.31% per combined admissions and presentations, or 6.58 medication errors per 1000 bed days. Children affected by a medication error were aged from the newborn to 27 years with a median age of 3.0 years (IQR, 4 months, 11 years). Young adults who had a long standing relationship with the hospital were able to continue to be cared for into their 20s; however, only 12 patients were over the age of 19 years. Female children comprised 44.4% of all medication errors (n = 1223). Medication errors occurred most commonly in the following settings: medical units (n = 473, 17.2%), surgical units (n = 443, 16.1%), and the intensive care unit (n = 338, 12.3%) (Table 1). Table 2 shows information about the date and time of reported errors. Severity outcomes of the 2753 medication errors were also examined (Table 3). This process was initially undertaken by the

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staff member reporting the error, and modified as necessary by staff from the Quality Unit of the hospital who held overall responsibility for review of reported medication errors. The two most common outcomes were: the medication error reached the child who required monitoring to confirm that it resulted in no harm (n = 1519, 55.2%) or the medication error occurred before it reached the child (n = 749, 27.2%). In relation to the errors

that caused harm (n = 99), an error rate of 0.011% per combined admissions and presentations or 0.24 per 1000 patient bed days was obtained. Causes of medication errors were determined in the comprehensive descriptions of reported incidents (Table 4). All reported medication errors were caused by some kind of communication problem in some way: the most common involved misreading

Table 1 Characteristics relating to clinical setting for reported medication errors (n = 2753)

Table 2 Characteristics relating to date and time for reported medication errors (n = 2753)

Variable

n

%

Variable

Setting of medication error Medical units Surgical units Intensive care unit Cardiac units Neonatal intensive care unit Oncology Neuroscience unit Emergency department Pharmacy department Immunology (vaccination unit) Perioperative area Hospital-in-the-home Psychiatric unit Outpatient units Radiology

473 443 338 283 241 200 194 135 114 97 77 62 39 39 18

17.2 16.1 12.3 10.3 8.8 7.3 7.0 4.9 4.1 3.5 2.8 2.3 1.4 1.4 0.7

Table 3

Year of medication error report 2006 (July 1–Dec 31) 2007 (Jan 1–Dec 31) 2008 (Jan 1–Dec 31) 2009 (Jan 1–Dec 31) 2010 (Jan 1–June 30) Time of day for medication error 0700 to 1530 h 1531 to 2130 h 2131 to 0659 h Occurrence of medication error Weekday Weekend Occurrence of medication error on a public holiday

n

%

302 638 677 788 348

11.1 23.2 24.6 28.6 12.6

1499 723 531

54.4 26.3 19.3

2210 543 31

80.3 19.7 1.1

Characteristics relating to outcomes of medication errors (n = 2753)

Outcome Situation was detected before it became a medication error (a near miss) Medication error occurred before it reached the child

Medication error reached the child but did not cause harm Medication error reached the child who required monitoring to confirm that no harm had occurred Medication error resulted in temporary harm that needed intervention or prolonged hospitalisation Medication error contributed to permanent harm or required an intervention to sustain life Medication error may have contributed to a child’s death

n

% 52

1.9

749

27.2

333

12.1

1520

55.2

90

3.2

8

0.3

1

0.04

Subcategory n (%) and examples Medication did not reach child 801 (29.1) e.g. Child was prescribed fluvoxamine. Doctor erroneously recharted flucloxacillin instead of fluvoxamine on a new medication chart. Error detected before administration. e.g. Nurse drew up prochlorperazine instead of promethazine for intravenous use, and double checked it with another nurse. Nurse realised error within minutes. Infusion stopped prior to any medication being delivered. Medication reached the child but essentially did not cause harm 1853 (67.3) e.g. Two nurses double checked and administered metronidazole, 375 mg intravenously. The order was for 375 mg of metronidazole orally. e.g. Child was administered an excessive dose of gentamicin. Maximum specified daily dose was 360 mg and child was given 600 mg intravenously. Medication reached the child and did cause harm 99 (3.5) e.g. Child (4.6 kg) was ordered and given 4.4 mL of magnesium sulphate 50% (2 mmol/mL) instead of 0.2 mL/kg (0.92 mL) according to guidelines. Respiratory saturations declined, and child became bradycardic. Magnesium level was elevated at 5.0 mmol/L. e.g. Child was ordered 4 mL of 1000 units/10 mL of heparin. Nurse drew up 4 mL of 5000 units/5 mL. Activated partial thromboplastin time (APTT) was greater than 180 s. and child required protamine reversal.

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Table 4 Causes relating to communication, name confusion, labelling, and human factors (n = 6046) Causes of medication errors

Causes relating to communication Misread or unread order Bedside communication Handover Units of measurement Misinterpretation of order Decimal point Telephone communication Illegible handwriting Ward round Causes relating to name confusion Generic name confusion Trade name confusion Causes relating to labelling Immediate container Label of supplied medication Printed or electronic reference material Causes related to human factors Performance deficit Miscalculation of dose or infusion rate Knowledge deficit Wrong amount of active medication used Wrong medication added to infusion Failure to activate delivery system properly Wrong diluent used for infusion Wrong amount of diluent used Inadequate screening of patient Error in stocking Intimidating behaviour Stress

n

%

Subcategory n (%) 2753 (45.5)

804 739 568 250 225 99 36 23 9

13.3 12.2 9.4 4.1 3.7 1.6 0.6 0.4 0.1

157 82

2.6 1.4

220 70 11

3.6 1.2 0.2

1440 521 157 157

23.8 8.6 2.6 2.6

149 112

2.5 1.9

100 36 30 25 18 8

1.7 0.6 0.5 0.4 0.3 0.1

239 (4.0)

301 (5.0)

2753 (45.5)

or not reading medication orders (n = 804, 29.2%). Problems with bedside communication was another common cause (n = 739; 26.8%). The key human factors associated with each medication error were also identified. The two most common human factors were performance deficit (n = 1446, 52.3%) and miscalculation of dose or rate (n = 521, 18.9%). Problems with labelling, either in relation to the immediate container, the label of the supplied medication, or the provision of printed and electronic reference material occurred in 301 (10.9%) medication errors. Name confusion with using generic or trade names was a problem in 239 (8.7%) medication errors. Interestingly, in 219 (8%) medication errors, children or family members had alerted health professionals about the error before health professionals were aware of the situation. Table 5 shows the types of medications errors that occurred and details about the people responsible. Common types of medication errors included overdose (n = 579, 21.0%) and dose omission (n = 341, 12.4%). Frequently-occurring medication groups implicated in dose omission, overdose and underdose 74

included: analgesics, such as the opioids and anti-infectives, such as penicillins. Analgesics and cardiovascular agents, such as intravenous adrenergic agents were commonly involved with wrong technique errors. Key contributing factors associated with medication errors included communication relating to patient movements (n = 929, 33.7%) and the lack of following policies and procedures (n = 617, 22.4%) (Table 6). In regards to people reporting medication errors, 1995 (72.5%) reports were made by nurses, 344 (12.5%) by doctors, 413 (15.0%) by pharmacists and 1 (0.04%) by a quality manager. People who were responsible for medication errors included: nurses (n = 1582, 57.5%), doctors (n = 957, 34.8%), pharmacists (n = 183, 6.6%), family members (n = 21, n = 0.8%), and patients (n = 10, 0.4%). Nurses were the health professionals most likely to report medication errors across all error types. The three most commonly reported medication groups were: anti-infective agents (n = 503, e.g. flucloxacillin, gentamicin), analgesics (n = 483, e.g. morphine, paracetamol), and fluids and electrolytes (n = 351, e.g. various concentrations of glucose, sodium chloride and potassium). For nurses, the most common types of error were administering overdoses with analgesics (n = 81) and using the wrong technique with analgesic infusions (n = 81) while for doctors, the most common type of medication error was prescribing overdoses with anti-infectives. For pharmacists, the most common types of medication error were supplying overdoses of immunomodulators and antineoplastics.

Discussion The medication error rate of 2753 medication errors over a 4-year period (6.58 medication errors per 1000 bed days) is higher than the reported rate by Ross et al.8 who found 195 errors over a 5-year period (0.51 per 1000 bed days) in a UK children’s teaching hospital. However, the reported rate of this study is lower than the reported rate by Wilson et al.,10 who found 117 errors over a 2-year period (82.9 medication errors per 1000 bed days) in a UK paediatric cardiac ward and a paediatric cardiac intensive care unit. Such variations highlight inherent difficulties with making comparisons between reported rates. It is important to acknowledge that a voluntary system of reporting existed and it was constantly reinforced that clinicians would not be judged or reprimanded for medication errors they reported. This lack of fear of possible reprimand is reflected in the numbers of medication errors reported each year, ranging from 638 to 788 errors per year. Medication safety is a designated priority area for the hospital. Regular in-service education and multidisciplinary focus groups are conducted throughout the whole hospital, encouraging health professionals to report all medication errors as they occur, regardless of how trivial they may appear. The main criticism of a voluntary reporting method is the potential for under-reporting errors.20 Despite limitations of this method, the non-punitive approach encouraged health professionals to report medication errors, which in the past may have gone unreported either because of their perceived trivial nature or fear of disciplinary action. In a prospective observational cohort study by Kunac et al.,21 761 medication-related events were reported over a 12-week study period. Most events

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Table 5

Medication errors

Types of medication errors and the person responsible for each type of error (n = 2753)

Variable

n

%

Person responsible for each type of error (n) and top three medication classes (n)

Overdose

579

21.0

Dose omission

341

12.4

Wrong technique

324

11.8

Wrong medication

254

9.2

Extra dose

177

6.4

Wrong time

170

6.2

Underdose

136

4.0

Wrong strength or concentration

123

4.5

Too fast rate

99

3.6

Drug-drug interaction

86

3.1

Deteriorating medication

75

2.7

Clinical monitoring

69

2.5

Wrong duration

56

2.0

Wrong patient

56

2.0

Wrong dose form

55

2.0

Documented allergy

38

1.4

Disease-drug interaction

35

1.3

Too slow rate

34

1.3

Intravenous administration into tissue space Intravenous instead of naso or orogastric Intravenous instead of oral administration Intravenous instead of intramuscular

34

1.2

4

0.1

4

0.1

2

0.1

Intramuscular instead of intravenous

1

0.05

Intrathecal instead of intravenous

1

0.05

N: 239; D: 297l P: 37; Pt: 2; F: 4 Analgesics (n = 135); anti-infectives (n = 93); anticlotting agents (n = 52) N: 213; D: 109; P: 16; Pt: 2; F: 1 Anti-infectives (n = 76); analgesics (n = 41); cardiovascular (n = 28) N: 234; D: 72; P: 12; Pt: 2; F: 4 Analgesics (n = 103); cardiovascular (40); fluids & electrolytes (n = 37) N: 164; D: 58; P: 30; Pt: 1; F: 1 Fluids & electrolytes (n = 79); anti-infectives (n = 33); analgesics (n = 27) N: 105; D: 59; P: 3; Pt: 2; F: 8 Vaccines (n = 39); analgesics (n = 34); anti-infectives (n = 33) N: 106; D: 57; P: 7; Pt: 0; F: 0 Anti-infectives (n = 52); analgesics (n = 22); cardiovascular (n = 18) N: 59; D: 66; P: 11; Pt: 0; F: 0 Analgesics (n = 31); anti-infectives (n = 23); anticlotting agents (n = 14) N: 84; D: 24; P: 15; Pt: 0; F: 0 Fluids & electrolytes (n = 61); analgesics (n = 11); anti-infectives (n = 10) N: 76; D: 23; P: 0; Pt: 0; F: 0 Fluids & electrolytes (n = 45); parenteral nutrition (n = 15); anti-infectives (n = 9) N: 63; D: 20; P: 3; Pt: 0; F: 0 Anti-infectives (n = 30); analgesics (n = 16); cardiovascular (n = 7); parenteral nutrition (n = 7) N: 48; D: 2; P: 24; Pt: 1; F: 0 Vaccines (n = 11); cardiovascular (n = 9); parenteral nutrition (n = 8) P: 30; D: 37; P: 1; Pt: 0; F: 1 Anti-infectives (n = 30); immunomodulators & antineoplastics (n = 10); cardiovascular (n = 6); fluids & electrolytes (n = 6) N: 28; D: 24; P: 4; Pt: 0; F: 0 Anti-infectives (n = 21); gastrointestinal (n = 7); immunomodulators & antineoplastics (n = 6) N: 36; D: 8; P: 12; Pt: 0; F: 0 Analgesics (n = 10); anti-infectives (n = 8); fluids & electrolytes (n = 6); immunomodulators & antineoplastics (n = 6) N: 29; D: 20; P: 6; Pt: 0; F: 0 Anti-infectives (n = 13); analgesics (n = 11); gastrointestinal (n = 10) N: 5; D: 32; P: 0; Pt: 0; F: 1 Anti-infectives (n = 22); analgesics (n = 4); immunomodulators & antineoplastics (n = 4); vaccines (n = 3) N; 7; D: 27; P: 1; Pt: 0; F: 0 Anti-infectives (n = 10); analgesics (n = 9); gastrointestinal (n = 3); fluids & electrolytes (n = 3) N: 29; D: 4; P: 0; Pt: 0; F: 1 Fluids & electrolytes (n = 18); parenteral nutrition (n = 4); analgesics (n = 3) N: 21; D: 13; P: 0; Pt: 0; F: 0 Vaccines (n = 10); analgesics (n = 5); anti-infectives (n = 4); fluids & electrolytes (n = 4) N: 3; D: 1; P: 0; Pt: 0; F: 0 Anti-infectives (n = 2); gastrointestinal (n = 1); immunomodulators & antineoplastics (n = 1) N: 3; D: 1; P: 0; Pt: 0; F: 0 Gastrointestinal (n = 3); fluids & electrolytes (n = 1) N: 0; D: 2; P: 0; Pt: 0; F: 0 Gastrointestinal (n = 1); vaccines (n = 1) N: 1; D: 0; P: 0; Pt: 0; F: 0 Anti-infectives (n = 1) N: 0; D: 0; P: 1; Pt: 0; F: 0 Immunomodulators & antineoplastics (n = 1)

Note: N refers to Nurse, D refers to Doctor, P refers to Pharmacist, Pt refers to Patient, and F refers to Family Member.

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Table 6

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Types of medication errors and contributing factors (n = 2753)

Variable

n

%

Communication relating to patient movements Policies and procedures Frequent interruptions and distractions Lack of available trained health professionals Insufficient or incorrect counselling offered to patients or parents Floor stock Inadequate training provided

929 617 543 260 219

33.7 22.4 19.7 9.5 8.0

102 83

3.7 3.0

(n = 630, 83.3%) were identified by chart review, 14.6% (n = 111) by a voluntary quality improvement process; 2.1% (n = 16) by interview, and 0.53% (n = 4) by an incident reporting system. Thus, extrapolating these events to a 4-year period, approximately 69 events would have been reported through an incident reporting system. Clearly, in the current study, health professionals reported a much higher proportion of medication errors than in Kunac et al.’s study (n = 2753). Nevertheless, it is possible that the number of reported medication errors did not closely reflect the number that actually occurred. Problems with written communication commonly related to misreading or not reading medication orders, and misinterpretation of medication orders. Electronic medication management systems in conjunction with clinical decision support can produce computer-generated orders that not only eliminate illegible handwriting but also have automated computer screening for determining allergies, drug-drug interactions, and duplicated therapy.22 However, electronic prescribing can cause new types of errors.23 In situations relating to weight-based prescribing for children, use of shortcut or default selections can be overridden by clinicians, which may result in toxic doses. Frequent alerts displayed by clinical decision support methods can also interrupt work flow, causing these alerts to be ignored by clinicians.24 At the time of the investigation, the study hospital did not have an electronic medication management system. Frequent medication error types related to dose omission and overdose. Clinical settings that were most commonly involved with dose omission included general medicine, general surgery and cancer care. In general medicine, children were often on many different medications, which sometimes could have led to distractions and forgetfulness in administering medications. In general surgery, as children moved between the operating room and post-surgical setting, gaps in communicating medication decisions at handover, caused problems with missing doses. In cancer care wards, as nurses spent extensive periods organising chemotherapy to be delivered, problems occurred in missing supportive therapy such as antiemetic agents. Settings commonly involving overdose errors included general medicine, general surgery and intensive care. In these settings, overdose problems frequently related to lack of understanding about dose protocols, and problems in monitoring intravenous equipment. Comparisons with past work involving rural and regional hospitals show that overdoses and underdoses are common problems,25,26 as are dose omissions.26 The use of an incorrect 76

technique has not been identified as a major problem in rural settings compared to this study.26 Common contributing factors included communication problems as children moved between environments, lack of attention to policies and protocols, and distractions and interruptions. Four clinical settings that consistently demonstrated problems with these contributing factors were intensive care, neonatal intensive care, general medical and general surgical settings. Intensive care and neonatal intensive care are environments where critically-ill infants and children require titrations of several medications and extensive monitoring of haemodynamic status. General medical and surgical wards may be staffed by inexperienced clinicians who rotate through their placements and are confronted with difficulties in having to make medication decisions in busy settings. Strategies can be implemented that provide specific training to these health professionals. Limitations of the study include its retrospective nature and the use of a single centre. Accuracy of findings is also dependent on health professionals’ documentation of medication errors. Nevertheless, most entries involved extensive descriptions of medication errors. Future research should focus on implementing and evaluating strategies aimed at reducing medication errors relating to analgesics, anti-infectives, cardiovascular agents, fluids and electrolytes and anticlotting agents, as they are consistently represented in the types of medication errors that occur. Greater attention needs to be placed on supporting health professionals in managing these medications. Doctors and pharmacists should be educated about the importance in reporting medication errors.

References 1 Kaushal R, Goldmann DA, Keohane CA et al. Adverse drug events in pediatric outpatients. Ambul. Pediatr. 2007; 7: 383–9. 2 Sanghera N, Chan PY, Khaki ZF et al. Interventions of hospital pharmacists in improving drug therapy in children – a systematic literature review. Drug Saf. 2006; 29: 1031–47. 3 Gonzales K. Medication administration errors and the pediatric population: a systematic search of the literature. J. Pediatr. Nurs. 2010; 25: 555–65. 4 Wong ICK, Wong LYL, Cranswick NE. Minimising medication errors in children. Arch. Dis. Child. 2009; 94: 161–4. 5 Kozer E, Berkovitch M, Koren G. Medication errors in children. Pediatr. Clin. North Am. 2006; 53: 1155–68. 6 Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009; 32: 379–89. 7 Cowley E, Williams R, Cousins D. Medication errors in children: a descriptive summary of medication error reports submitted to the United States Pharmacopeia. Curr. Ther. Res. Clin. Exp. 2001; 26: 627–40. 8 Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch. Dis. Child. 2000; 83: 492–6. 9 Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet 1989; 2: 374–6. 10 Wilson DG, McArtney RG, Newcombe RG et al. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur. J. Pediatr. 1998; 157: 769–74.

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11 Bordun LA, Butt W. Drug errors in intensive care. J. Paediatr. Child Health 1992; 28: 309–11. 12 Marino B, Reinhardt K, Eichelberger W, Steingard R. Prevalence of errors in a pediatric hospital medication system: implication for error proofing. Outcomes Manag. Nurs. Pract. 2000; 4: 129–35. 13 Kaushal R, Jaggi T, Walsh K, Fortescue EB, Bates DW. Pediatric medication errors: what do we know? What gaps remain? Ambul. Pediatr. 2004; 4: 73–81. 14 Fortescue EB, Kaushal R, Landrigan CP et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. J. Pediatr. 2003; 111: 722–9. 15 Payne CH, Smith CR, Newkirk LE, Hicks RW. Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data. AORN J. 2007; 85: 731–44. 16 Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008. Aust. New Zealand Health Policy 2009. doi:0.1186/743-8462-6-18. 17 Dawson K, Penna A, Drummond D, Sharpe C. Prescription errors in a children’s ward: audit and intervention. Aust. J. Hosp. Pharm. 1993; 23: 326–8. 18 Titchen T, Cranswick N, Beggs S. Adverse drug reactions to nonsteroidal anti-inflammatory drugs, COX-2 inhibitors and

19

20 21 22 23 24

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paracetamol in a paediatric hospital. Br. J. Clin. Pharmacol. 2005; 59: 718–23. National Coordinating Council for Medication Error Reporting and Prevention. About medication errors. 2011. Available from: http://www.nccmerp.org/aboutMedErrors.html [accessed 10 May 2011]. Snyder RA, Fields W. A model for medication safety event detection. Int. J. Qual. Health Care 2010; 22: 179–86. Kunac D, Reith D. Preventable medication-related events in hospitalised children in New Zealand. N. Z. Med. J. 2008; 121: 17–32. Simons J. Identifying medication errors in surgical prescription charts. Paediatr. Nurs. 2010; 22: 20–4. Christian S, Gyves H, Manji M. Electronic prescribing. Care Crit. Ill 2004; 20: 68–71. Manias E, Williams A, Liew D. Interventions to reduce medication errors in adult intensive care: a systematic review. Br. J. Clin. Pharmacol. 2012; 74: 411–23. Campino A, Lopez-Herrera MC, Lopez-de-Heredia I, Valls-i-Soler A. Medication errors in a neonatal intensive care unit. influence of observation on the error rate. Acta Paediatr. 2008; 97: 1591–4. Marcin JP, Dharmar M, Cho M et al. Medication errors among acutely ill and injured children treated in rural emergency departments. Ann. Emerg. Med. 2007; 50: 361–7.

Splat creature, drawing by Alida Yamazaki (age 4).

Journal of Paediatrics and Child Health 50 (2014) 71–77 © 2013 The Authors Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

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Medication errors in hospitalised children.

This study aims to explore the characteristics of reported medication errors occurring among children in an Australian children's hospital, and to exa...
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