Reducing Medication Errors in Children’s Hospitals

Abstract

ObjectivesKnowledge of the prevalence and characteristics of medication errors in pediatric and neonatal patients is limited. This study aimed to evaluate the incidence and medication error characteristics in a pediatric hospital over 5 years and to determine whether serial error prevention programs to optimize a computerized physician order entry (CPOE) system reduce error incidence.MethodsWe retrospectively reviewed medication errors documented between January 2015 and December 2019.ResultsA total of 2,591,596 prescriptions were checked, and 255 errors were identified. Wrong dose prescriptions constituted the most common errors (56.9%). Medications with the highest rate of errors were antibiotics/antiviral drugs (36.9%). Oral route medications comprised the highest portion (60.8%), followed by intravenous ones (28.6%). The most common stage for medication errors was physician ordering (93.3%). Junior residents were responsible for most errors (45.9%). Most errors occurred in the pediatric ward (53.7%). In total, 221 (86.7%) errors were near misses. Only 4 errors (1.6%) were considered significant and required active monitoring or intervention. Type of error, stage of error, staff composition, and severity level of errors were significantly related to the number of errors in different years. There was a statistically significant decrease in errors per 100,000 prescriptions across different years after optimizing the CPOE system.ConclusionsThe incidence of medication errors decreased with extensive use of the CPOE system. Continuous application of the CPOE optimization program can effectively reduce medication errors. Further incorporation of pediatric-specific decision-making and support tools and error prevention measures into CPOE systems is needed.

Healthcare Worker’s Satisfaction Assessment for a Healthcare Adverse Event Reporting Framework and the Management Approach for Such Reporting in the Emergency Department of Rural Government Hospitals

“…One study by Kottapalli et al in 2023 [ 13 ] aimed to identify staff education requirements on safe injection and infusion practices. Another study by Liu et al in 2023 [ 14 ] looked back over five years in a pediatric hospital to assess the occurrence and features of medication errors. In a retrospective cohort study conducted by Mira et al in 2023 [ 15 ] in primary care settings in Spain, the frequency and severity of adverse events that occur when do-not-do (DND) recommendations are ignored were determined.…”

Medication Errors: Detection Methodology Matters

“…Contributing factors to having a medication error were age, assistance with medical technology, and numbers of complex chronic conditions and medications. Although the patient populations and reporting metrics are different, their error rate and contributing factors are different than those reported by Liu et al 1 This difference between the rate and characteristics of errors based on detection methodology has been described in the adult intraoperative population, where Stipp et al 3 reported an error detection difference of 0.004% versus 5.3% between SR versus DO methodology, respectively. A direct comparison of the difference in error capture within the same pediatric clinical setting has yet to be performed.…”

“…L iu et al's study, "Reducing medication errors in children's hospitals," in the April 2023 issue of your journal, provides an interesting characterization of medication errors in pediatric and neonatal patients in Taiwan. 1 The authors report an analysis of 255 errors over 2,591,596 prescriptions across inpatient and outpatient settings, an error rate of 0.0098%. In their report, most errors were on the inpatient pediatric ward (as opposed to intensive care units) and were related to prescription.…”

Impact of pharmaceutical validation on prescribing errors in a neonatal intensive care unit. Randomised and controlled study

“…Specifically, medication errors are common and occur at a high rate (4)(5)(6) in NICUs, and neonates in NICUs experience significantly higher medication errors and adverse drug event rates than that experienced by neonates of other wards (6). Although higher incidence of error in pediatric wards compared to neonatal wards has been also found (7), NICUs have a significantly higher rate of potential or preventable adverse drug events compared with pediatric intensive care units (6).…”