A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children’s Intensive Care

Abstract

Background Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas. Objective This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs). Methods We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents. Results In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols. Conclusions Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.

Incidence and nature of adverse drug events in paediatric intensive care units: A prospective multicentre study

“…We have recently conducted a study to explore underlying contributory factors associated with medication‐related incidents reported from PICUs across England and Wales between 2010 and 2018 31 . We found that the busy and pressurised working environment of the ICU, inadequate guidelines, staffing, systems and policies were commonly involved with harmful incidents.…”

Association between professional qualification and adverse events in neonatal and pediatric intensive treatment units

“…Although AEs related to medication administration are the most frequent occurrences in health services, including NICUs and PICUs (2) , this problem was detected in a single patient in the present study. It is inferred that these events may have been underreported in the investigated units, as their identification directly depends on the quality/reliability of the information in the medical records.…”

“…On the other hand, it is believed that the low prevalence of these AEs is related to the length of professional experience and the qualification of workers for neonatal and pediatric care, as newly graduated professionals and teams not trained and not familiar with institutional safety policies were described as factors that contributed to the events arising from the use of medications (2) .…”

“…In the aforementioned areas, the use of various technologies, care associated to a critical clinical condition, work overload, non-compliance with guidelines and care protocols and the inadequate transition of neonatal and pediatric patient care maximize the cases of adverse events (AE) (2) . These are defined as care-related incidents that result in harm to the patient (3) .…”

Evaluation of the effect of a Nursing System Framework on Nurse Sensitive Indicators, mortality and readmission in an NHS Trust

“…The association between the quality of nursing care provided and its direct impact on patient outcomes has been reported in the literature. Examples include: Alghamdi et al (2021), Cannaby et al (2017), Estabrooks et al (2005), Jabbal, 2017, Kelly et al (2014), Lawton et al, 2014, McHugh et al (2013) Zwillinger and Huster (2017), West (2021).…”