216 Medication Errors in Paediatrics: PAtient, Pill and Process. (October 2012)

• Record Type: Journal Article
• Authors: Maaskant, J; Zwart, E; Bosman, D; Flint, R; Vermeulen, H
• Is Part Of: Archives of disease in childhood. Volume 97(2012)Supplement 2
• Page Start: A62
• Page End: A62
• Publication Date: 2012-10
• Subjects: Children -- Diseases -- Periodicals; Infants -- Diseases -- Periodicals; 618.920005
• DOI: 10.1136/archdischild-2012-302724.0216
• Languages: English
• ISSNs: 0003-9888

Abstract

Abstract : Background and aims: Medication errors, defined as preventable events that may lead to incorrect medication use or patient harm, is a big problem in healthcare. Especially children are considered to be at high risk of experiencing harm due to medication errors. Interventions to prevent errors have led to limited improvements. If, however, we could identify error prone situations, more effective interventions could be developed and thereby prevent patient harm. The purpose of this study was to establish the prevalence of harm due to medication errors categorized in characteristics of P atients and P ills in all phases of the medication P rocess. Methods: We investigated medication errors using a multifaceted approach including direct observations, and review of patients' files, pharmacy logs and voluntary incidents reports. All medication errors were classified in terms of (potential) patient harm. Results: We collected data of 426 patients admitted to five paediatric, non-ICU wards during three months. In 236 patients at least one medication error was identified: 55% (236/426). A total of 39 errors were harmful affecting 37 patients: 9% (37/426). Significantly more harmful medication errors were found in patients after surgery: 68% (25/37). In 59% (23/39)of the ADEs analgesics were involved: non-opioids 49% (19/39) and opioids 10% (4/39). Prescribing and administrating were the most error prone activities: 28% (11/39)and 62% (24/39). Conclusions: Our results identified error prone P atients, P ills and medication P rocess. This will guide future targeted interventions to improve medication safety for children.