Evidence of frequent dosing errors in paediatrics and intervention to reduce such prescribing errors

Bolt, Robert J.; Yates, Julian; Mahon, James; Bakri, I.

doi:10.1111/jcpt.12114

Cited by 12 publications

(7 citation statements)

References 16 publications

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“…Seven studies were set in or included critical care data – six in Paediatric Intensive Care (PICU) [31–36] and one in Neonatal Intensive Care (NICU) [37]. There were three studies examining medicines reconciliation (1 on discharge and 2 on admission to hospital) [38–40], 16 studies explored MPEs [31–37, 41–49]; six studies examined medication administration (four studying MAEs [31, 50–52], and two studying the incidence of adverse drug reactions.) [53, 54] Two studies examined the incidence of DRPs as a specific concept using the Pharmaceutical Care Network Europe (PCNE)classifications [55, 56].…”

Section: Resultsmentioning

confidence: 99%

“…Three studies used a retrospective approach [41, 45, 46] and 23 used prospective designs. Retrospective studies all used longitudinal cohort study designs ranging from 1 month to 1 year, while prospective studies lasted between 1 day and 10 months.…”

Section: Resultsmentioning

confidence: 99%

“…Two studies reported data on technical prescribing errors, defined as a failure to complete prescriptions in line with local policy [44, 47]. Five studies did not define “error” [32, 33, 36, 41, 45, 46].…”

Section: Resultsmentioning

confidence: 99%

“…It was possible to extract data on error rates for dosing errors from five studies [31, 41, 42, 47, 48]. These data are presented in Table 3.…”

Section: Resultsmentioning

confidence: 99%

“…(P) – prospective; (R) – retrospective. PICU/NICU data has been excludedObserved ordersDosingErrors%Bolt (R) [41]991313Davey (R) [42]764660.5Ghaleb (P) [31]3914411.2Lepee (P) [47]657172.6O’Meara (P) [48]1911562.9…”

Section: Resultsmentioning

confidence: 99%

See 4 more Smart Citations

Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

et al. 2019

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BackgroundProblems arising from medicines usage are recognised as a key patient safety issue. Children are a particular concern, given that they are more likely than adults to experience medication-related harm. While previous reviews have provided an estimate of prevalence in this population, these predate recent developments in the delivery of paediatric care. Hence, there is a need for an updated, focussed and critical review of the prevalence and nature of drug-related problems in hospitalised children in the UK, in order to support the development and targeting of interventions to improve medication safety.MethodsNine electronic databases (Medline, Embase, CINAHL, PsychInfo, IPA, Scopus, HMIC, BNI, The Cochrane library and clinical trial databases) were searched from January 1999 to April 2019. Studies were included if they were based in the UK, reported on the frequency of adverse drug reactions (ADRs), adverse drug events (ADEs) or medication errors (MEs) affecting hospitalised children. Quality appraisal of the studies was also conducted.ResultsIn all, 26 studies were included. There were no studies which specifically reported prevalence of adverse drug events. Two adverse drug reaction studies reported a median prevalence of 25.6% of patients (IQR 21.8–29.9); 79.2% of reactions warranted withdrawal of medication. Sixteen studies reported on prescribing errors (median prevalence 6.5%; IQR 4.7–13.3); of which, the median rate of dose prescribing errors was 11.1% (IQR 2.9–13). Ten studies reported on administration errors with a median prevalence of 16.3% (IQR 6.4–23). Administration technique errors represented 53% (IQR 52.7–67.4) of these errors. Errors detected during medicines reconciliation at hospital admission affected 43% of patients, 23% (Range 20.1–46) of prescribed medication; 70.3% (Range 50–78) were classified as potentially harmful. Medication errors detected during reconciliation on discharge from hospital affected 33% of patients and 19.7% of medicines, with 22% considered potentially harmful. No studies examined the prevalence of monitoring or dispensing errors.ConclusionsChildren are commonly affected by drug-related problems throughout their hospital journey. Given the high prevalence and risk of patient harm,, there is a need for a deeper theoretical understanding of paediatric medication systems to enable more effective interventions to be developed to improve patient safety.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

“…It was possible to extract data on error rates for dosing errors from five studies [31, 41, 42, 47, 48]. These data are presented in Table 3.…”

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

et al. 2019

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Validation of a mobile app for reducing errors of administration of medications in an emergency

Baumann

Dibbern

Sehner

et al. 2018

J Clin Monit Comput

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Medication errors occur frequently and are a risk to patient safety. To reduce mistakes in the medication process in emergencies, a mobile app has been developed supporting the calculation of doses and administration of drugs. A simulation study was performed to validate the app as a tool to reduce medication errors. This was a randomised crossover study conducted in the Academic Hospital. The participants included were residents and attendings in anaesthesiology. 74 Participants performed four simulation scenarios in which they had to calculate and administer drugs for emergencies. Two scenarios were performed with the app ("app scenarios") and the other two scenarios were performed without the use of the app ("control scenarios"). The order of drugs, simulation patients and usage of aid were randomized. The accuracy of administered drug doses were measured. Medications were categorised as either "accurate" ([Formula: see text]% of target dosage) or "wrong" (less than 50% or more than 200% of target dosage). The dosage calculated and the dosage administered were documented separately to differentiate between calculation and handling errors. During app scenarios, there were no "wrong" dosages, whereas 6.8 (95% CI 2.7-10.8%) of dosages in control scenarios were evaluated as "wrong". The probability of giving an "accurate" dosage was increased from 77.7 (70.9-84.5%) in control scenarios to 93.9 (90-97.8%) in app scenarios. Calculation errors were the main cause for wrong dosing. The app is an appropriate and feasible tool to reduce calculation and handling errors and may increase patient safety.

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Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention

Goedecke¹,

Ord²,

Newbould³

et al. 2016

Drug Saf

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A medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to, harm to the patient. Reducing the risk of medication errors is a shared responsibility between patients, healthcare professionals, regulators and the pharmaceutical industry at all levels of healthcare delivery. In 2015, the EU regulatory network released a two-part good practice guide on medication errors to support both the pharmaceutical industry and regulators in the implementation of the changes introduced with the EU pharmacovigilance legislation. These changes included a modification of the 'adverse reaction' definition to include events associated with medication errors, and the requirement for national competent authorities responsible for pharmacovigilance in EU Member States to collaborate and exchange information on medication errors resulting in harm with national patient safety organisations. To facilitate reporting and learning from medication errors, a clear distinction has been made in the guidance between medication errors resulting in adverse reactions, medication errors without harm, intercepted medication errors and potential errors. This distinction is supported by an enhanced MedDRA(®) terminology that allows for coding all stages of the medication use process where the error occurred in addition to any clinical consequences. To better understand the causes and contributing factors, individual case safety reports involving an error should be followed-up with the primary reporter to gather information relevant for the conduct of root cause analysis where this may be appropriate. Such reports should also be summarised in periodic safety update reports and addressed in risk management plans. Any risk minimisation and prevention strategy for medication errors should consider all stages of a medicinal product's life-cycle, particularly the main sources and types of medication errors during product development. This article describes the key concepts of the EU good practice guidance for defining, classifying, coding, reporting, evaluating and preventing medication errors. This guidance should contribute to the safe and effective use of medicines for the benefit of patients and public health.

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Evidence of frequent dosing errors in paediatrics and intervention to reduce such prescribing errors

Cited by 12 publications

References 16 publications

Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

Mapping the prevalence and nature of drug related problems among hospitalised children in the United Kingdom: a systematic review

Validation of a mobile app for reducing errors of administration of medications in an emergency

Medication Errors: New EU Good Practice Guide on Risk Minimisation and Error Prevention

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