How to avoid paediatric medication errors: a user's guide to the literature

Walsh, Kathleen E.; Kaushal, Rainu; Chessare, John B.

doi:10.1136/adc.2003.048827

Cited by 80 publications

(54 citation statements)

References 34 publications

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“…48,49 Pediatric medication incidents (including their extent and methods to reduce them) have been extensively explored in the hospital setting, but less so in family practice. 43,47,[50][51][52][53][54] Our findings emphasize the importance of verification procedures and support barcode scanning of medications during dispensing and using generic medication names (rather than brand names) to reduce mistakes from inattention or distraction and communication errors. [55][56][57] …”

Section: Discussionmentioning

confidence: 97%

Safety Incidents in the Primary Care Office Setting

et al. 2015

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Section: Discussionmentioning

confidence: 97%

Safety Incidents in the Primary Care Office Setting

et al. 2015

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“…12,17,18 The use of liquid doses forms in out patients setting in paediatrics is an important contributing factor for medication error. 19 The use of graduated caps or standard measuring methods should be advised to patient particularly in out patients settings if the drug are to be dispensed in liquid doses forms to minimize the medication error. Overall the observation on the listing of more than one antibiotic in a prescription was minimal in comparison to other studies but was in consistent to the observation made by Karande et al, where they have noted only three prescription containing two antibiotics out of 198 prescriptions with antibiotics.…”

Section: Discussionmentioning

confidence: 99%

Assessment of drug use pattern for lower respiratory tract infection in outpatient department of paediatric at central referral hospital: a cross-sectional study

Sharma

Endow

Dutta

2017

Int J Basic Clin Pharmacol

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Background: Prescription audit is an important tool to analyse rational use of drug at different health sectors. The aim of the study was to evaluate the prescribing pattern using World Health Organization prescribing indicators for lower respiratory tract infection in children below five years of age.Methods: A cross-sectional study was conducted in the outpatient department of Paediatrics at Central Referral Hospital, Gangtok, Sikkim, India for a period of 18 months. Study involved children between 1-5 years of age with fever/cough with or without respiratory distress. The data were collected from the out patient department prescription slips as well as interviewing the parents/guardians after finishing the physician consultation. The data were processed using statistical software SPSS 20.Results: The study was conducted with 57 prescriptions comprising 210 drugs from both male (54.38%) and female (45.61%) patients. The average number of drugs per prescription was found to be 3.68. negligible (0.013%) prescription containing generic name of drug was found, 96.66% of medicines were prescribed from National Essential List of Medicine (NELM). No prescriptions were found to have injectables, 8.57% of the prescriptions were found to contain fixed dose combination. Amongst the drug categories, salbutamol accounted for 23.33% in total prescription followed by paracetamol (22.85%) and amoxicillin (7.14%). While accounting for the formulations used, the maximum prescriptions were containing syrup followed by nebulization.Conclusions: The use of generic names was minimal, only few of the prescriptions had vitamins and tonics with no use of injectable preparations. Maximum numbers of drugs were prescribed from NELM.

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“…For example, in hospitals, the medication administration stage accounts for 26-32% of adult patient medication errors and 4-60% of paediatric patient medication errors. 9 Evidence shows that Barcode Medication Administration (BCMA) systems can reduce pharmacy dispensing errors, 10 hence they have been strongly recommended for all hospitals in the USA. However, a study published in 2008 identified 15 types of BCMA-related workarounds and 31 separate probable causes of the identified workarounds, along with potential errors as a result of workaround occurrence.…”

Section: A New Hot Cheese Modelmentioning

confidence: 99%

Hot cheese: a processed Swiss cheese model

Li¹,

Thimbleby²

2014

J R Coll Physicians Edinb

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James Reason's classic Swiss cheese model is a vivid and memorable way to visualise how patient harm happens only when all system defences fail. Although Reason's model has been criticised for its simplicity and static portrait of complex systems, its use has been growing, largely because of the direct clarity of its simple and memorable metaphor. A more general, more flexible and equally memorable model of accident causation in complex systems is needed. We present the hot cheese model, which is more realistic, particularly in portraying defence layers as dynamic and active -more defences may cause more hazards. The hot cheese model, being more flexible, encourages deeper discussion of incidents than the simpler Swiss cheese model permits. KeywORDS education, human error, incident causation model DeClARATION Of INTeReSTS THe ORIGINAl SwISS CHeeSe MODelThe SCM has been an extraordinarily good education tool. In formal use, it has been considered useful because of its clarifying role in accident investigation and because it can help identify potential hazards (e.g. missing defences) before harm happens. Notably, instead of focusing blame or investigative efforts on the person who apparently committed the active failure that caused an incident -for example, a nurse who administrated an overdose to a patient -the SCM encourages investigators to view such actions just as one unsafe act in a chain of many, rather than the only cause.The SCM helps us understand active failures and latent conditions (Figure 1). Active failures are generally committed by persons who perform their duty at the so-called sharp end 7 of the system (visualised to the left in Figure 1). Latent conditions are the potential contributing factors that lie dormant in the system and occur upstream at the more remote layers, called the blunt end.7 These latent conditions can be organisational, contextual and diffuse in nature, or they may be designrelated, to do with the system that people work in. Their consequences only become evident when they combine with other factors to breach system defences.Here is an example. Administering the wrong drug is an active failure, but the latent condition might have been the confusingly similar names of two different drugs. In the SCM, both types of failure are represented the same way, as holes in defences. In particular, the SCM gains power by not differentiating between the 'sharp end' failures and the 'blunt end' failures. A hole is a hole, and it does not matter where it is; if an incident occurs, every defence failed, and seeking the root cause is misleading. Thus the SCM helps stop us focusing just on the sharp end active failures, such as the 'nurse pressing the wrong button'. This insight is nicely captured in the slogan 'system flaws, not character flaws'. 8 The SCM makes it clear that blame cannot be placed on problems involving just one slice of cheese; indeed, it would be a system design flaw to rely on only one defence for any critical process.Anything from poorly designed policy, untimel...

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How to avoid paediatric medication errors: a user's guide to the literature

Cited by 80 publications

References 34 publications

Safety Incidents in the Primary Care Office Setting

Safety Incidents in the Primary Care Office Setting

Assessment of drug use pattern for lower respiratory tract infection in outpatient department of paediatric at central referral hospital: a cross-sectional study

Hot cheese: a processed Swiss cheese model

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