Reducing medication errors in the neonatal intensive care unit

Adverse events and other incidents in neonatal intensive care units

The occurrence of avoidable adverse events (AEs) represents a problem of quality of care that is responsible for the increase in monetary and social costs, causing suffering to the patient, their family members and the professional involved. This situation is aggravated when it involves newborns (NBs) with very low birth weights and shorter gestational ages, admitted to neonatal intensive care units (NICU). The scope of this study is to understand more about these incidents and adverse events in NICUs. The article aims to identify the occurrence of incidents, with and without injury that have occurred in NICUs in the literature and correlate this with the gestational age group of the NBs most affected. This is a systematic review of the available literature on incidents, particularly AEs as witnessed in NICUs. This study reveals that the types of incidents that occur in NICUs, with or without injury to the patient, are related to errors or failures in medication use, healthcare-associated infections (HAIs), skin injuries, mechanical ventilation and intravascular catheters. The cause of incidents and adverse events in NICUs are associated with human factors and the outcomes that are most damaging are due to HAIs. Furthermore, the study points out ways to mitigate these occurrences.

Use of the Delphi technique to determine safety features to be included in a neonatal and paediatric prescription chart

BACKGROUND

Neonatal and paediatric patients are especially vulnerable to serious injury as a result of medication errors due to their small size, physiological immaturity and limited compensatory abilities. The prescription chart remains an essential form of communication of prescribing decisions and instructions. Modifications to the safety features of prescription charts have been shown to reduce the frequency of medication errors.

OBJECTIVE

To determine, using the Delphi technique, which safety features should be included in the inpatient neonatal and paediatric prescription chart to help minimise the risk of medication errors associated with the use of the chart.

SETTING

Acute general hospital in Malta.

METHOD

A two-round modified e-Delphi process was conducted. The Delphi questionnaire was developed from a mapping process, a literature search and references supporting the literature review. It comprised 155 safety features for consensus. The Delphi panel consisted of nine doctors, five nurses and four pharmacists. Participants were asked to rate their agreement to the inclusion of these features in the local chart using a three-point Likert scale, and to add further comments as necessary at the end of each section. In the second round, participants were given the opportunity to change their individual response in view of the groups' response.

MAIN OUTCOME MEASURE

This was set at a 70% level of agreement.

RESULTS

Results from each round were analysed to provide the percentage frequencies and number of participants who chose each point from the Likert scale provided, and the response count for each safety feature. A ≥70% consensus level was achieved on: 115 safety features in Round 1 (total: 155 safety features) and 23 safety features in Round 2 (total: 40 safety features) while only 17 safety features did not achieve consensus at the end of the process.

CONCLUSION

Consensus was achieved on 133 safety features to be included in the neonatal and paediatric prescription chart. Five safety features achieved consensus disagreement for their inclusion in the chart. Identifying the appropriate safety features forms part of an essential strategy to reduce the incidence of medication errors associated with the use of the chart in these patients.

Preventing medication errors in neonatology: Is it a dream?

Since 1999, the problem of patient safety has drawn particular attention, becoming a priority in health care. A “medication error” (ME) is any preventable event occurring at any phase of the pharmacotherapy process (ordering, transcribing, dispensing, administering, and monitoring) that leads to, or can lead to, harm to the patient. Hence, MEs can involve every professional of the clinical team. MEs range from those with severe consequences to those with little or no impact on the patient. Although a high ME rate has been found in neonatal wards, newborn safety issues have not been adequately studied until now. Healthcare professionals working in neonatal wards are particularly susceptible to committing MEs due to the peculiarities of newborn patients and of the neonatal intensive care unit (NICU) environment. Current neonatal prevention strategies for MEs have been borrowed from adult wards, but many factors such as high costs and organizational barriers have hindered their diffusion. In general, two types of strategies have been proposed: the first strategy consists of identifying human factors that result in errors and redesigning the work in the NICU in order to minimize them; the second one suggests to design and implement effective systems for preventing errors or intercepting them before reaching the patient. In the future, prevention strategies for MEs need to be improved and tailored to the special neonatal population and the NICU environment and, at the same time, every effort will have to be made to support their clinical application.

Interventions to reduce medication errors in pediatric intensive care

OBJECTIVE

To systematically examine the research literature to identify which interventions reduce medication errors in pediatric intensive care units.

DATA SOURCES

Databases were searched from inception to April 2014.

STUDY SELECTION AND DATA EXTRACTION

Studies were included if they involved the conduct of an intervention with the intent of reducing medication errors.

DATA SYNTHESIS

In all, 34 relevant articles were identified. Apart from 1 study, all involved single-arm, before-and-after designs without a comparative, concurrent control group. A total of 6 types of interventions were utilized: computerized physician order entry (CPOE), intravenous systems (ISs), modes of education (MEs), protocols and guidelines (PGs), pharmacist involvement (PI), and support systems for clinical decision making (SSCDs). Statistically significant reductions in medication errors were achieved in 7/8 studies for CPOE, 2/5 studies for ISs, 9/11 studies for MEs, 1/2 studies for PGs, 2/3 studies for PI, and 3/5 studies for SSCDs. The test for subgroup differences showed that there was no statistically significant difference among the 6 subgroups of interventions, χ(2)(5) = 1.88, P = 0.87. The following risk ratio results for meta-analysis were obtained: CPOE: 0.47 (95% CI = 0.28, 0.79); IS: 0.37 (95% CI = 0.19, 0.73); ME: 0.36 (95% CI = 0.22, 0.58); PG: 0.82 (95% CI = 0.21, 3.25); PI: 0.39 (95% CI = 0.10, 1.51), and SSCD: 0.49 (95% CI = 0.23, 1.03).

CONCLUSIONS

Available evidence suggests some aspects of CPOE with decision support, ME, and IS may help in reducing medication errors. Good quality, prospective, observational studies are needed for institutions to determine the most effective interventions.

Medication errors of nurses in the emergency department

Patient safety is one of the main concepts in the field of healthcare provision and a major component of health services quality. One of the important stages in promotion of the safety level of patients is identification of medication errors and their causes. Medical errors such as medication errors are the most prevalent errors that threaten health and are a global problem. Execution of medication orders is an important part of the treatment and care process and is regarded as the main part of the nurses' performance. The purpose of this study was to explore the medication error reporting rate, error types and their causes among nurses in the emergency department. In this descriptive study, 94 nurses of the emergency department of Imam Khomeini Hospital Complex were selected based on census in 2010-2011. Data collection tool was a researcher-made questionnaire consisting of two parts: demographic information, and types and causes of medication errors. After confirming content-face validity, reliability of the questionnaire was determined to be 0.91 using Cronbach's alpha test. Data analyses were performed by descriptive statistics and inferential statistics. SPSS-16 software was used in this study and P values less than 0.05 were considered significant. The mean age of the nurses was 27.7 ± 3.4 years, and their working experience was 7.3 ± 3.4 years. Of participants 46.8% had committed medication errors in the past year, and the majority (69.04%) had committed the errors only once. Thirty two nurses (72.7%) had not reported medication errors to head nurses or the nursing office. The most prevalent types of medication errors were related to infusion rates (33.3%) and administering two doses of medicine instead of one (23.8%). The most important causes of medication errors were shortage of nurses (47.6%) and lack of sufficient pharmacological information (30.9%). This study showed that the risk of medication errors among nurses is high and medication errors are a major problem of nursing in the emergency department. We recommend increasing the number of nurses, adjusting the workload of the nursing staff in the emergency department, retraining courses to improve the staff's pharmacological information, modification of the education process, encouraging nurses to report medical errors and encouraging hospital managers to respond to errors in a constructive manner in order to enhance patient safety.

Paediatric nurses' adherence to the double-checking process during medication administration in a children's hospital: an observational study

AIM

To evaluate how closely double-checking policies are followed by nurses in paediatric areas and also to identify the types, frequency and rates of medication administration errors that occur despite the double-checking process.

BACKGROUND

Double-checking by two nurses is an intervention used in many UK hospitals to prevent or reduce medication administration errors. There is, however, insufficient evidence to either support or refute the practice of double-checking in terms of medication error risk reduction.

DESIGN

Prospective observational study.

METHODS

This was a prospective observational study of paediatric nurses' adherence to the double-checking process for medication administration from April-July 2012.

RESULTS

Drug dose administration events (n = 2000) were observed. Independent drug dose calculation, rate of administering intravenous bolus drugs and labelling of flush syringes were the steps with lowest adherence rates. Drug dose calculation was only double-checked independently in 591 (30%) drug administrations. There was a statistically significant difference in nurses' adherence rate to the double-checking steps between weekdays and weekends in nine of the 15 evaluated steps. Medication administration errors (n = 191) or deviations from policy were observed, at a rate of 9·6% of drug administrations. These included 64 drug doses, which were left for parents to administer without nurse observation.

CONCLUSION

There was variation between paediatric nurses' adherence to double-checking steps during medication administration. The most frequent type of administration errors or deviation from policy involved the medicine being given to the parents to administer to the child when the nurse was not present.

The effectiveness of an e-learning program on pediatric medication safety for undergraduate students: a pretest-post-test intervention study

BACKGROUND

Safe medication management is a major competency taught in the nursing curriculum. However, administering pediatric medications is considered a common clinical stressor for Taiwanese students. A supplemental e-learning program that helps students fill the gap between basic nursing skills and pediatric knowledge on medication safety was developed.

OBJECTIVE

To evaluate the effectiveness of an e-learning program to increase pediatric medication management among students who take pediatric nursing courses.

DESIGN

This intervention study used a historical comparison design.

SETTING

A university in Northern Taiwan.

PARTICIPANTS

A total of 349 undergraduate nursing students who took pediatric nursing courses participated. Eighty students in the comparison group received regular pediatric courses, including the lectures and clinical practicum; 269 students in the intervention group received an e-learning program, in addition to the standard pediatric courses.

METHODS

Between February 2011 and July 2012 pediatric medication management, including pediatric medication knowledge and calculation ability, was measured at the beginning of the first class, at the completion of the lectures, and at the completion of the clinical practicum. The program was evaluated qualitatively and quantitatively.

RESULTS

The intervention group had significantly higher pediatric medication management scores at completion of the lecture course and at the completion of the clinical practicum than the comparison group based on the first day of the lecture course, after adjusting for age, nursing program, and having graduated from a junior college in nursing. Overall, the students appreciated the program that included various teaching modalities content that related to the administration of medication.

CONCLUSION

Using an e-learning program on pediatric medication management is an effective learning method in addition to sitting in a regular lecture course. The different emphases in each module, provided by experienced instructors, enabled the students to be more aware of their role in pediatric medication safety.

A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers

AIMS

Prescribing is a complex task and a high risk area of clinical practice. Poor prescribing occurs across staff grades and settings but new prescribers are attributed much of the blame. New prescribers may not be confident or even competent to prescribe and probably have different support and development needs than their more experienced colleagues. Unfortunately, little is known about what interventions are effective in this group. Previous systematic reviews have not distinguished between different grades of staff, have been narrow in scope and are now out of date. Therefore, to inform the design of educational interventions to change prescribing behaviour, particularly that of new prescibers, we conducted a systematic review of existing hospital-based interventions.

METHODS

Embase, Medline, SIGLE, Cinahl and PsychINFO were searched for relevant studies published 1994-2010. Studies describing interventions to change the behaviour of prescribers in hospital settings were included, with an emphasis on new prescibers. The bibliographies of included papers were also searched for relevant studies. Interventions and effectiveness were classified using existing frameworks and the quality of studies was assessed using a validated instrument.

RESULTS

Sixty-four studies were included in the review. Only 13% of interventions specifically targeted new prescribers. Most interventions (72%) were deemed effective in changing behaviour but no particular type stood out as most effective.

CONCLUSION

Very few studies have tailored educational interventions to meet needs of new prescribers, or distinguished between new and experienced prescribers. Educational development and research will be required to improve this important aspect of early clinical practice.

Evaluation of the identification protocol for newborns in a private hospital

This exploratory-descriptive quantitative study aimed to evaluate the protocol for identifying newborns admitted to the Neonatal Intensive and Semi-intensive Therapy Unit of a private hospital. The case series was made up of 540 observation opportunities, selected by simple random probability sampling. The data was collected between May and August 2010 according to a form and analyzed by descriptive statistic. The protocol's general performance had a conformity index of 82.2%. There were three stages to the protocol: identification components, the identification wristbands' condition and the number of identification wristbands. The highest percentage of conformity (93%) was attributed to the second stage and the lowest (89.3%) to the third, presenting a statistically significant difference of p= 0.046. In the group of 'special' neonates, 88.5% conformity was achieved. These results will make it possible to restructure the protocol for identifying newborns and to establish care and managerial goals so as to improve the quality of care and the patients' safety.

[From iatrogenesis to medical errors: review of the literature and analytical approach]

Iatrogenesis and medical errors have been increasingly studied over the past years. Because of the lack of consensus concerning the definitions, it remains difficult to draw general conclusions from the published. Moreover, it is still likely to be underestimated because of underreporting. This review aims at evaluating the overall incidence of iatrogenesis and medical errors in anaesthesia and intensive care and at discussing the strategies to prevent these incidents, at the individual or systemic level.

Reducing prescribing errors in the paediatric intensive care unit: an experience from Egypt

AIM

To investigate the impact of different measures, implemented by clinical pharmacists, on prescribing error rates in a paediatric intensive care unit (PICU) in Cairo, Egypt.

METHODS

We performed a pre-post study of prescribing errors in a 12 bed PICU. We utilized a chart review method for the detection of prescribing errors. The rate and potential severity of prescribing errors were determined before and then after the implementation of the medication error reducing measures. These measures included the use of a new structured medication order chart, physician education, provision of dosing assists and physician performance feedback.

RESULTS

We evaluated 1417 medication orders for 139 patients preintervention and 1097 orders for 101 patients postintervention. Of preintervention orders, 1107 (78.1%) had at least one prescribing error. The intervention resulted in significant reduction in prescribing error rate to 35.2% postintervention (p < 0.001). The intervention resulted also in a significant reduction in the rate of potentially severe errors from 29.7% preintervention to 7% postintervention (p < 0.001) and the rate of potentially moderate errors from 39.8% preintervention to 24.2% postintervention (p < 0.001). Besides, rates of all types of prescribing errors were declined to different degrees as a result of the intervention.

CONCLUSION

Clinical pharmacists' activities, focusing on improving physician-nurse communication, physician drug knowledge and awareness of errors, were shown effective in reducing the rate of prescribing errors and their potential severity in a PICU.

Reducing prescribing errors in paediatric patients by assessment and feedback targeted at prescribers

Prescribing errors are the most common type of medical errors and can result in harm particularly in young children. Doctors were enrolled in a programme of written assessment in prescribing skills and individualized feedback. Pharmacists audited the impact. The setting was the paediatric wards and neonatal unit of a District General Hospital. 16 doctors were tested and received feedback. A total of 110 errors were identified in this test, out of a 51 were classified as major including wrong dose and frequency, and prescribing medication the patient had an allergy to. Audit of impact of this intervention revealed a reduction of errors from 47 to 21, and patients affected from 19 to 11 per 100 (P = 0.001) emergency admissions compared to an audit before the intervention. An intervention combining a comprehensive multifaceted assessment and detailed feedback can lead to reduction of prescribing errors in paediatric trainees.

Improving the quality of drug error reporting

BACKGROUND

Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections.

AIM

The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital.

METHODS

A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi-disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting.

RESULTS

The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems-based. Staff felt obliged to report but rarely received feedback. IMPLICATIONS AND CONCLUSION: Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi-centred evaluation.

Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring

OBJECTIVES

To assess the impact of continuous incident reporting and subsequent prevention strategies on the incidence of severe iatrogenic events and targeted priorities in admitted neonates.

METHODS

We performed preintervention (January 1 to September 1, 2005) and postintervention (January 1, 2008, to January 1, 2009) prospective investigations based on continuous incident reporting. Patient-safety initiatives were implemented for a period of 2 years. The main outcome was a reduction in the incidence of severe iatrogenic events. Secondary outcomes were improvements in 5 targeted priorities: catheter-related infections; invasive procedures; unplanned extubations; 10-fold drug infusion-rate errors; and severe cutaneous injuries.

RESULTS

The first and second study periods included totals of 388 and 645 patients (median gestational ages: 34 and 35 weeks, respectively; P = .015). In the second period the incidence of severe iatrogenic events was significantly reduced from 7.6 to 4.8 per 1000 patient-days (P = .005). Infections related to central catheters decreased significantly from 13.9 to 8.2 per 1000 catheter-days (P < .0001), as did exposure to central catheters, which decreased from 359 to 239 days per 1000 patient-days (P < .0001). Tenfold drug-dosing errors were reduced significantly (P = .022). However, the number of unplanned extubations increased significantly from 5.6 to 15.5 per 1000 ventilation-days (P = .03).

CONCLUSIONS

Prospective, continuous incident reporting followed by the implementation of prevention strategies are complementary procedures that constitute an effective system to improve the quality of care and patient safety.

Evaluation of tools to prevent drug incompatibilities in paediatric and neonatal intensive care units

OBJECTIVE

Intravenous drug administration in neonatal (NICU) and paediatric intensive care units (PICU) is critical because of poor venous access, polymedication, fluid restriction and low infusion rate. Risk is further increased by inadequate information on the physicochemical compatibility of drugs. Eight decision-supporting tools were hence evaluated to improve the detection of drug incompatibilities in paediatric wards.

SETTING

NICU and PICU, University hospital.

METHOD

Eight tools (Thériaque 2007, Stabilis 3, Perfysi 2 databases; KIK 3.0 software; Neofax 2007 handbook; King 2008 Guide, CHUV 9.0, pH 2007 cross-tables) were assessed by two pharmacists using 40 drug pairs (20 incompatible; 20 compatible) frequently prescribed in PICUs and NICUs. Trissel's 14th Ed. handbook served as the gold standard. Four criteria were evaluated (each with a maximum of 250 points): accuracy (sensitivity, specificity, positive and negative predictive values), completeness (number of drug pairs documented), comprehensiveness (presence of 16 different items), and applicability (by combining the time needed by 7 pharmacists to classify 5 drug pairs, plus an evaluation of their design, usefulness, reliability and ergonomics, using visual analogy scales). The percentage of non-compliant answers (NCA) was calculated for both the performing pharmacists and the tools.

MAIN OUTCOME MEASURE

Global score of drug incompatibilities (accuracy + completeness + comprehensiveness + applicability).

RESULTS

Thériaque obtained the best global score (840/1000 points), followed by pH (807), CHUV (803), Perfysi (776), Neofax (678), King Guide (642), Stabilis (584) and KIK (523), respectively. The highest scores were reached by Thériaque for accuracy (234/250); Thériaque and pH for completeness (200/250); Thériaque and Perfysi for comprehensiveness (218/250); and pH for applicability (298/250). The range of pharmacists' NCAs was between 9% (4/45 NCAs) and 33% (15/45), whereas that for drug pairs was between 10% (6/63) and 30% (19/63). The range of NCAs for tools was between 6% (2/35, pH) and 49% (18/35, Perfysi).

CONCLUSIONS

Thériaque proved outstanding as a drug-incompatibility tool. However, all resources showed some shortcomings. The large ranges of pharmacists' NCAs shows that such an assessment is subject to different interpretations. Standard operating procedures for drug-incompatibility assessment should be implemented in drug-information centres. Tools with low NCA percentage, such as the pH or CHUV tables, may be useful for nurses in ICUs.

Random safety auditing, root cause analysis, failure mode and effects analysis

Improving quality and safety in health care is a major concern for health care providers, the general public, and policy makers. Errors and quality issues are leading causes of morbidity and mortality across the health care industry. There is evidence that patients in the neonatal intensive care unit (NICU) are at high risk for serious medical errors. To facilitate compliance with safe practices, many institutions have established quality-assurance monitoring procedures. Three techniques that have been found useful in the health care setting are failure mode and effects analysis, root cause analysis, and random safety auditing. When used together, these techniques are effective tools for system analysis and redesign focused on providing safe delivery of care in the complex NICU system.

Physician order entry or nurse order entry? Comparison of two implementation strategies for a computerized order entry system aimed at reducing dosing medication errors

BACKGROUND

Despite the significant effect of computerized physician order entry (CPOE) in reducing nonintercepted medication errors among neonatal inpatients, only a minority of hospitals have successfully implemented such systems. Physicians' resistance and users' frustration seem to be two of the most important barriers. One solution might be to involve nurses in the order entry process to reduce physicians' data entry workload and resistance. However, the effect of this collaborative order entry method in reducing medication errors should be compared with a strictly physician order entry method.

OBJECTIVE

To investigate whether a collaborative order entry method consisting of nurse order entry (NOE) followed by physician verification and countersignature is as effective as a strictly physician order entry (POE) method in reducing nonintercepted dose and frequency medication errors in the neonatal ward of an Iranian teaching hospital.

METHODS

A four-month prospective study was designed with two equal periods. During the first period POE was used and during the second period NOE was used. In both methods, a warning appeared when the dose or frequency of the prescribed medication was incorrect that suggested the appropriate dosage to the physicians. Physicians' responses to the warnings were recorded in a database and subsequently analyzed. Relevant paper-based and electronic medical records were reviewed to increase credibility.

RESULTS

Medication prescribing for 158 neonates was studied. The rate of nonintercepted medication errors during the NOE period was 40% lower than during the POE period (rate ratio 0.60; 95% confidence interval [CI] .50, .71;P < .001). During the POE period, 80% of nonintercepted errors occurred at the prescription stage, while during the NOE period, 60% of nonintercepted errors occurred in that stage. Prescription errors decreased from 10.3% during the POE period to 4.6% during the NOE period (P < .001), and the number of warnings with which physicians complied increased from 44% to 68% respectively (P < .001). Meanwhile, transcription errors showed a nonsignificant increase from the POE period to the NOE period. The median error per patient was reduced from 2 during the POE period to 0 during the NOE period (P = .005). Underdose and curtailed and prolonged interval errors were significantly reduced from the POE period to the NOE period. The rate of nonintercepted overdose errors remained constant between the two periods. However, the severity of overdose errors was lower in the NOE period (P = .02).

CONCLUSIONS

NOE can increase physicians' compliance with warnings and recommended dose and frequency and reduce nonintercepted medication dosing errors in the neonatal ward as effectively as POE or even better. In settings where there is major physician resistance to implementation of CPOE, and nurses are willing to participate in the order entry and are capable of doing so, NOE may be considered a beneficial alternative order entry method.

An interprofessional approach to improving paediatric medication safety

BACKGROUND

Safe drug prescribing and administration are essential elements within undergraduate healthcare curricula, but medication errors, especially in paediatric practice, continue to compromise patient safety. In this area of clinical care, collective responsibility, team working and communication between health professionals have been identified as key elements in safe clinical practice. To date, there is limited research evidence as to how best to deliver teaching and learning of these competencies to practitioners of the future.

METHODS

An interprofessional workshop to facilitate learning of knowledge, core competencies, communication and team working skills in paediatric drug prescribing and administration at undergraduate level was developed and evaluated. The practical, ward-based workshop was delivered to 4th year medical and 3rd year nursing students and evaluated using a pre and post workshop questionnaire with open-ended response questions.

RESULTS

Following the workshop, students reported an increase in their knowledge and awareness of paediatric medication safety and the causes of medication errors (p < 0.001), with the greatest increase noted among medical students. Highly significant changes in students' attitudes to shared learning were observed, indicating that safe medication practice is learnt more effectively with students from other healthcare disciplines. Qualitative data revealed that students' participation in the workshop improved communication and teamworking skills, and led to greater awareness of the role of other healthcare professionals.

CONCLUSION

This study has helped bridge the knowledge-skills gap, demonstrating how an interprofessional approach to drug prescribing and administration has the potential to improve quality and safety within healthcare.

Safety and Risk Management Interventions in Hospitals

The aim of this systematic review was (a) to synthesize the evidence on the effectiveness of detection, mitigation, and actions to reduce risks in hospitals and (b) to identify and describe components of interventions responsible for effectiveness. Thirteen literature databases were explored using a structured search and data extraction strategy. All included studies dealing with incident reporting described positive effects. Evidence regarding the effectiveness and efficiency of safety analysis is scarce. No studies on mitigation were included. The collected evidence on risk reduction concerns a variety of interventions to reduce medication errors, fall incidents, diagnostic errors, and adverse events in general. Most studies reported positive effects; however, interventions were often multifaceted, and it was difficult to disentangle their impact. This made it difficult to draw generic lessons from this body of research. More rigorous evaluations are needed, in particular, of continuous learning and safety analysis techniques.

The effect of Computerized Physician Order Entry and decision support system on medication errors in the neonatal ward: experiences from an Iranian teaching hospital

Medication dosing errors are frequent in neonatal wards. In an Iranian neonatal ward, a 7.5 months study was designed in three periods to compare the effect of Computerized Physician Order Entry (CPOE) without and with decision support functionalities in reducing non-intercepted medication dosing errors in antibiotics and anticonvulsants. Before intervention (Period 1), error rate was 53%, which did not significantly change after the implementation of CPOE without decision support (Period 2). However, errors were significantly reduced to 34% after that the decision support was added to the CPOE (Period 3; P < 0.001). Dose errors were more often intercepted than frequency errors. Over-dose was the most frequent type of medication errors and curtailed-interval was the least. Transcription errors did not reduce after the CPOE implementation. Physicians ignored alerts when they could not understand why they appeared. A suggestion is to add explanations about these reasons to increase physicians' compliance with the system's recommendations.

Pediatric safety incidents from an intensive care reporting system

OBJECTIVES

Adverse events impose a great burden on patients and the health care system, but not enough is known about how to address incidents involving pediatric patients. This study examined the demographic factors, types of events, contributing system factors, and harm associated with incidents that occur in pediatric intensive care units.

METHODS

Cross-sectional analysis of 2 years of data on all pediatric safety incidents and near misses reported to the voluntary provider-recorded Intensive Care Unit Safety Reporting System in regards to harm and contributing factors.

RESULTS

In 464 incidents reported from 23 intensive care units to the Intensive Care Unit Safety Reporting System, patients were physically injured in one third of incidents and harmed in some way in two thirds of incidents. Medication errors were the most common incident type, but were associated with less harm than other event types. Line, tube, and airway events comprised one third of incidents and were associated with more harm than other types. Patient contributing factors were a strong predictor of harm; training and education factors were also commonly cited. In multivariate analysis, patient factors were the strongest predictor of harm adjusting for age, sex, and race.

CONCLUSIONS

Pediatric patients are commonly harmed in intensive care units. There are several potential ways to improve safety including protocols for high-risk procedures involving lines and tubes, improved monitoring, and staffing, training and communication initiatives. Providers may be able to identify patients at increased risk for harm and intervene to protect patient safety.

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics

Laboratory diagnostics, a pivotal part of clinical decision making, is no safer than other areas of healthcare, with most errors occurring in the manually intensive preanalytical process. Patient misidentification errors are potentially associated with the worst clinical outcome due to the potential for misdiagnosis and inappropriate therapy. While it is misleadingly assumed that identification errors occur at a low frequency in clinical laboratories, misidentification of general laboratory specimens is around 1% and can produce serious harm to patients, when not promptly detected. This article focuses on this challenging issue, providing an overview on the prevalence and leading causes of identification errors, analyzing the potential adverse consequences, and providing tentative guidelines for detection and prevention based on direct-positive identification, the use of information technology for data entry, automated systems for patient identification and specimen labeling, two or more identifiers during sample collection and delta check technology to identify significant variance of results from historical values. Once misidentification is detected, rejection and recollection is the most suitable approach to manage the specimen.

Reducing medication prescribing errors in a teaching hospital

BACKGROUND

Medication errors occur frequently, result in significant morbidity and mortality, and are often preventable. A multifaceted intervention was conducted to reduce prescribing errors in handwritten medication orders written by house staff.

METHODS

A before-and-after design was used to evaluate the intervention--which included grand rounds, an interactive presentation for house staff, and reminders (a checklist, chart inserts, and requests for clarification)--and targeted 20 safe prescribing behaviors.

RESULTS

At baseline, prescribing errors were more common among surgical house staff than medical house staff (1.08 errors/order versus 0.76 errors/order, p < .001). Only 1% of orders contained an overt error, but 49% were incomplete, 27% contained dangerous dose and frequency abbreviations, and 17% were illegible. Postintervention, the mean number of prescribing errors per order decreased for surgical house staff from 1.08 (standard deviation [SD], 0.23) to 0.85 (SD, 0.11; p < .001), with a more marked effect for house staff who attended the didactic portion of the intervention. In addition, the mean number of the more significant errors per order decreased from 0.65 (SD, 0.19) to 0.45 (SD, 0.13; p < .001), and significant decreases occurred in the proportion of orders that were incomplete, were illegible, and contained an overt error. However, prescribing errors per order increased in orders written by medical house staff from 0.76 (SD, 0.14) to 0.98 (SD, 0.11; p < .001).

DISCUSSION

The intervention was associated with a modest improvement in the quality of medication orders written by surgical house staff. To reduce prescribing errors, multilevel interventions are needed, including training in safe prescribing for all physicians. Such training may need to be started in medical school and augmented and reinforced throughout residency.

Iatrogenesis in neonatal intensive care units: observational and interventional, prospective, multicenter study

OBJECTIVES

The goals were to determine the incidence of iatrogenic events in NICUs and to determine whether awareness of iatrogenic events could influence their occurrence.

METHODS

We performed a prospective, observational, interventional, multicenter study including all consecutive infants hospitalized in 4 NICUs. In the first 3 months (observation period), the medical teams were unaware of the study; in the next 3 months (intervention period), they were made aware of daily ongoing monitoring of iatrogenic events by a designated "Iatrogenesis Advocate."

RESULTS

The numbers of infants admitted to the NICUs were comparable during the observation and intervention periods (328 and 369 infants, respectively). There was no difference between the 2 periods with respect to the number of infants of <1500 g, hospitalization days, or mean daily occupancy of the NICUs. Although the prevalence rates of iatrogenic events were comparable in the observation and intervention periods (18.0 and 18.2 infants with iatrogenic events per 100 hospitalized infants, respectively), the incidence rate decreased significantly during the intervention period (3.2 and 2.4 iatrogenic events per 100 hospitalization days of new admissions, respectively). Of all iatrogenic events, 7.9% were classified as life-threatening and 45.1% as harmful. There was no death related to an iatrogenic event. Eighty-three percent of iatrogenic events were considered preventable, of which 26.9% resulted from medical errors in ordering or delivery of medical care. Only 1.6% of all iatrogenic events were intercepted before reaching the infants, and only 47.0% of iatrogenic events were corrected. For younger and smaller infants, the rate of iatrogenic events was higher (57% at gestational ages of 24 to 27 weeks, compared with 3% at term) and the iatrogenic events were more severe and harmful. Increased length of stay was associated independently with more iatrogenic events.

CONCLUSIONS

Neonatal medical teams and parents should be aware of the burden of iatrogenesis, which occurs at a significant rate.

Iatrogenic disorders in modern neonatology: a focus on safety and quality of care

The introduction of new modalities of treatment for the very premature infant and advanced life-support systems have led to a decrease in the neonatal mortality rate, and a consequent increase in the population of the tiniest survivors. Many premature infants that survive their neonatal intensive care unit stay have permanent injury to their vital organs including eyes, lungs, brain, and gastrointestinal tract, causing them to have lifelong disabilities. Whether these injuries are a result of their prematurity, or are caused by the life-support systems and treatments is a subject of much dispute. This article explains the process of iatrogenicity and separates the iatrogenic problems that are preventable from those that are currently unpreventable.

Medication errors in neonates

Prevention of harm from medication errors has become a national priority. Medication errors in the neonatal intensive care unit are common, and most can be avoided. This article reviews the prevalence and types of medication errors affecting the care of the neonate and summarizes approaches that have been used to reduce these errors. Safety initiatives applicable to minimizing medication errors also are discussed.

Computer-related medication errors in neonatal intensive care units

Iatrogenic medication errors in the neonatal ICU (NICU) are reported to occur up to 2.6 times per 100 NICU days. It has been learned during the last decade that well-intended but faulty implementations of technology can increase the frequency of errors and also can give rise to new types. This article compares and discusses iatrogenic medication errors in the NICU that are related to computer entry and computerized physician order entry systems. The authors also propose a possible approach for evaluating technology that is intended to prevent iatrogenic mediation errors in the NICU.

Iatrogenic events in admitted neonates: a prospective cohort study

BACKGROUND

Iatrogenic events are increasingly recognised as an important problem in all people admitted to hospital. However, few epidemiological data are available for iatrogenic events in neonatal high-risk units. We aimed to assess the incidence, nature, preventability, and severity of iatrogenic events in a neonatal centre and to establish the association of patient characteristics with the occurrence of iatrogenic events in neonates.

METHODS

We undertook an observational, prospective study from Jan 1, 2005, to Sept 1, 2005, including all neonates admitted in the Division of Neonatology of an academic, tertiary neonatal centre in southern France. Iatrogenic events were defined as any event that compromised the safety margin for the patient, in the presence or absence of harm. The report of an iatrogenic event was voluntary, anonymous, and non-punitive. The primary outcome was the rate of iatrogenic events per 1000 patient days.

FINDINGS

A total of 388 patients were studied during 10 436 patient days. We recorded 267 iatrogenic events in 116 patients. The incidence of iatrogenic events was 25.6 per 1000 patient days. 92 (34%) were preventable and 78 (29%) were severe. Two iatrogenic events (1%) were fatal, but neither was preventable. The most severe iatrogenic events were nosocomial infections (49/62 [79%]) and respiratory events (nine of 26 [35%]). Cutaneous injuries were frequent (n=94) but generally minor (89 [95%]), as were medication errors (15/19 [76%]). Most medication errors occurred during administration stage (12/19 [63%]) and were ten-fold errors (nine of 19 [47%]). The major risk factors were low birthweight and gestational age (both p<0.0001), length of stay (p<0.0001), a central venous line (p<0.0001), mechanical ventilation (p=0.0021), and support with continuous positive airwary pressure (p=0.0076).

INTERPRETATION

Iatrogenic events occur frequently and are often serious in neonates, especially in infants of low birthweight. Improved knowledge of the incidence and characteristics of iatrogenic events, and continuous monitoring could help to improve quality of health care for this vulnerable population.

Designing medication safety in the NICU

IN SEPTEMBER 2006, A HOSPITAL IN Indianapolis, Indiana, reported that six premature babies had been given adult-size doses of heparin, resulting in the death of three of the infants.1 The adult doses of this blood thinner had inadvertently been placed in a medication cabinet in the NICU. Similar packaging of the adult and neonatal doses contributed to this human error. When used correctly, medications can save neonates’ lives. When incorrectly used, they can cost the lives of the very patients they are intended to help.2

Interventions to reduce dosing errors in children: a systematic review of the literature

Children are a particularly challenging group of patients when trying to ensure the safe use of medicines. The increased need for calculations, dilutions and manipulations of paediatric medicines, together with a need to dose on an individual patient basis using age, gestational age, weight and surface area, means that they are more prone to medication errors at each stage of the medicines management process. It is already known that dose calculation errors are the most common type of medication error in neonatal and paediatric patients. Interventions to reduce the risk of dose calculation errors are therefore urgently needed. A systematic literature review was conducted to identify published articles reporting interventions; 28 studies were found to be relevant. The main interventions found were computerised physician order entry (CPOE) and computer-aided prescribing. Most CPOE and computer-aided prescribing studies showed some degree of reduction in medication errors, with some claiming no errors occurring after implementation of the intervention. However, one study showed a significant increase in mortality after the implementation of CPOE. Further research is needed to investigate outcomes such as mortality and economics. Unit dose dispensing systems and educational/risk management programmes were also shown to reduce medication errors in children. Although it is suggested that 'smart' intravenous pumps can potentially reduce infusion errors in children, there is insufficient information to draw a conclusion because of a lack of research. Most interventions identified were US based, and since medicine management processes are currently different in different countries, there is a need to interpret the information carefully when considering implementing interventions elsewhere.

Improving the quality of medical prescriptions in neonatal units

BACKGROUND

Pediatric units, especially neonatal units, are highly vulnerable to error generally and to medication error in particular. Potential failures are distributed across the entire medication process, occurring mostly at the time of medication prescription and during preparation for drug administration.

OBJECTIVE

To estimate the prevalence of violations of good prescribing practice before and after the implementation of several measures aimed at improving the quality of the medical prescription.

METHODS

Before and after evaluation study with prospective data collection in a third level neonatal unit. 6,320 handwritten medical prescriptions for neonates admitted in the first study period and 1,435 in the second period were analyzed. Training on good prescribing practice and the implementation of a pocket PC-based automatic dosage calculation system were the interventions. The main outcome measure was the proportion of prescriptions with violations of good prescribing practice: incorrect dose, units, dose interval, route of administration or legibility.

RESULTS

Incorrect prescriptions decreased from 39.5% before the intervention to 11.9% after, with an adjusted prevalence ratio of 0.29 (0.25-0.34). The number of wrongly specified items on a single prescription decreased from 11.1% of the prescriptions with two or more wrongly specified items in the first period to 1.3% in the second period, with a prevalence ratio of 0.09 (0.05-0.14).

CONCLUSIONS

Violations of good prescribing practice are common in neonatal units. A simple intervention should improve the quality of handwritten medical prescriptions for newborns admitted to intensive care settings.

A summary of NICU fat emulsion medication errors and nursing services: data from MEDMARX

Intralipid infusions remain a critical part of ensuring adequate nutritional supplement and growth in premature and term infants. Managing intralipid therapy requires great care to prevent metabolic and physiological side effects. The authors sought to systematically study medication errors associated with intralipid administration in the neonatal intensive care unit (NICU). A descriptive quantitative and qualitative analysis incorporating secondary data was used. Medication error data were drawn from 54 institutions that voluntarily participated with MEDMARX, a national, Internet-accessible medication error reporting program owned and operated by the United States Pharmacopeia. These errors were associated with NICUs, and each medication error record identified nursing staff as making the initial error. A total of 257 errors were reviewed, with 3.9% resulting in harm. The mean age of the neonate was 7 days, and more errors occurred on Mondays than any other day of the week. Errors disproportionately occurred between 6 pm and midnight, with a significant difference between errors near 7 am and 7 pm (P = .002). Wrong dose errors occurred in 69% of the sample. Nearly one quarter of the errors resulted from misprogramming infusion devices (either pumps or syringes). Qualitative findings revealed that many of the errors were the result of the nurse's misinterpretation of the modes (ie, time, volume, or rate) on the infusion device or by not recognizing the decimal point on the device's display panel. Several errors involved switching the rate of infusion with total parenteral nutrition and that of intralipids. Voluntary medication error reporting offers valuable insights into intralipid errors occurring in NICUs. Secondary analysis is an ethical, economic means of studying the occurrence of such errors. MEDMARX data suggest that some of the serious errors are the result of complex care and equipment needed for these vulnerable infants.

Adverse drug events in hospitalized cardiac patients

Little information is available concerning adverse drug events (ADEs) in cardiac patients. Therefore, the investigators report the results of cardiac patients in an ADE surveillance program, with the intent of reducing the frequency of future events. All reported adverse drug reactions and medication errors in cardiac patients over a 5-year period at Brigham and Women's Hospital were reviewed. There were 547 ADEs in cardiac patients, a rate of 1.9 events for every 100 patient admissions. Preventable ADEs most often occurred during medication administration (34.2%), with wrong rate or frequency of medication administration the most widespread event. Cardiovascular agents (29.8%), anticoagulants (28.5%), and antimicrobial agents (10.8%) were the most common drug classes associated with ADEs. Injury or prolonged hospitalization occurred in 5.3% of patients. ADEs occurred most frequently on the admission day, on weekdays, and in the early morning hours. Peak frequencies of ADEs coincided with nursing shift changes. In conclusion, ADEs occur often in hospitalized cardiac patients and affect 2 of every 100 patient admissions. Given the high percentage of ADEs associated with drug administration, more resources should be directed at this step of medication use. Focusing interventions around nursing shift changes may further enhance preventive strategies.

Incidents and errors in neonatal intensive care: a review of the literature

OBJECTIVES

To examine the characteristics of incident reporting systems in neonatal intensive care units (NICUs) in relation to type, aetiology, outcome and preventability of incidents.

METHODS

Systematic review.

SEARCH STRATEGY

Medline, Embase, Cochrane Library. Included: relevant systematic reviews, randomised controlled trials, observational studies and qualitative research. Excluded: non-systematic reviews, expert opinions, case reports and letters.

PARTICIPANTS

hospital units supplying neonatal intensive care.

INTERVENTION

none.

OUTCOME

characteristics of incident reporting systems; type, aetiology, outcome and preventability of incidents.

RESULTS

No relevant systematic reviews or randomised controlled trials were found. Eight prospective and two retrospective studies were included. Overall, medication incidents were most frequently reported. Available data in the NICU showed that the total error rate was much higher in studies using voluntary reporting than in a study using mandatory reporting. Multi-institutional reporting identified rare but important errors. A substantial number of incidents were potentially harmful. When a system approach was used, many contributing factors were identified. Information about the impact of system changes on patient safety was scarce.

CONCLUSIONS

Multi-institutional, voluntary, non-punitive, system based incident reporting is likely to generate valuable information on type, aetiology, outcome and preventability of incidents in the NICU. However, the beneficial effects of incident reporting systems and consecutive system changes on patient safety are difficult to assess from the available evidence and therefore remain to be investigated.

Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety: a review of the current literature

Neonates are highly vulnerable to medication errors because of their extensive exposure to medications in the neonatal intensive care unit (NICU), the general lack of evidence on pharmacotherapeutic interventions in neonates and the lack of neonate-specific formulations. We searched PubMed and EMBASE to identify relevant original studies published in the English language. Eleven studies were identified on the frequency of medication errors in the NICU. The highest rate was 5.5 medication errors per 100 prescriptions; however, medication error rates varied widely between studies, partly due to differences in the definition of an error and the rigor of the method used to identify medication errors. Furthermore, studies were difficult to compare because medication error rates were calculated differently. Most studies did not assess the potential clinical impact of the errors. The majority of studies identified dose errors as the most common type of error. Computerised physician order entry and interventions by clinical pharmacists (e.g. the participation of pharmacists in ward rounds and review of patients' prescriptions prior to dispensing) were the most common interventions suggested to improve medication safety in the NICU. However, only very limited data were available on evaluation of the effects of such interventions in NICUs. More research is needed to determine the frequency and types of medication errors in NICUs and to develop evidence-based interventions to improve medication safety in the NICU setting. Some of these research efforts need to be directed to the establishment of clear definitions of medication errors and agreement on the methods that should be used to measure medication error rates and their potential clinical impact.

Pediatric patient safety in the prehospital/emergency department setting

The unique characteristics of the pediatric population expose them to errors in the emergency department (ED) with few standard practices for the safety of care. Young children and high-acuity patients are at increased risk of adverse events both in the prehospital and ED settings. We provide an overview of the problems and possible solutions to the threats to pediatric patient safety in the ED. Endorsing a culture of safety and training to work in a team are discussed. Medication errors can be reduced by using organizational systems, and manufacturing and regulatory systems, by educating health care providers, and by providing caregivers tools to monitor prescribing. The consensus is that a safe environment with a high quality of care will reduce morbidity and mortality in ED pediatric patients.

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations

BACKGROUND

Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children.

OBJECTIVE

To synthesise peer reviewed knowledge on children's medication errors and on recommendations to improve paediatric medication safety by a systematic literature review.

DATA SOURCES

PubMed, Embase and Cinahl from 1 January 2000 to 30 April 2005, and 11 national entities that have disseminated recommendations to improve medication safety.

STUDY SELECTION

Inclusion criteria were peer reviewed original data in English language. Studies that did not separately report paediatric data were excluded.

DATA EXTRACTION

Two reviewers screened articles for eligibility and for data extraction, and screened all national medication error reduction strategies for relevance to children.

DATA SYNTHESIS

From 358 articles identified, 31 were included for data extraction. The definition of medication error was non-uniform across the studies. Dispensing and administering errors were the most poorly and non-uniformly evaluated. Overall, the distributional epidemiological estimates of the relative percentages of paediatric error types were: prescribing 3-37%, dispensing 5-58%, administering 72-75%, and documentation 17-21%. 26 unique recommendations for strategies to reduce medication errors were identified; none were based on paediatric evidence.

CONCLUSIONS

Medication errors occur across the entire spectrum of prescribing, dispensing, and administering, are common, and have a myriad of non-evidence based potential reduction strategies. Further research in this area needs a firmer standardisation for items such as dose ranges and definitions of medication errors, broader scope beyond inpatient prescribing errors, and prioritisation of implementation of medication error reduction strategies.

[Medication administration errors in a pediatric intensive care unit]

The administration act, as each step of the drugs circuit, can lead to an adverse drug event potentially harmful for the patient. The aim of this study was to highlight the adverse drug events outcoming at the administration stage and to suggest improvement elements. Errors were identified in a retrospective manner. We compared the written prescriptions ("Prescription forms") with the administration registration ("Administration forms"). The differences observed between these two paper media were classified according to the errors types defined by the American Society of Hospital Pharmacists and by the American Society of Consultant Pharmacists. This study settled in the pediatric intensive care unit of a teaching hospital. We checked 1035 administrations lines: 180 errors (17,4%) were detected, including 63 omissions, 44 infusion rate errors, 42 administrations without prescription, 20 administration time errors, 7 dose errors, 2 drug form errors, 2 errors of other types, but no route of administration error. This method choice is debatable because without direct observation we could only compare what was noted to be administrated and not what was really administrated. We did not try to identify neither the causes nor the consequences of these errors on the patients. Following this study, several improvements have been set up: a new "Prescription form" (expecting the computerized prescription order entry) and reconstitution and dilution protocols for the most prescribed drugs.

Prescribing safely for children

This paper is the second in a series of two and will attempt to highlight important issues in prescribing for children, including principles of safe prescribing, adverse drug reaction assessment and common drugs including paracetamol and ibuprofen. A list of drug information resources is included, which may be useful for clinicians.

Neonatology in developed and developing nations

Neonatal care has made tremendous improvements in developing countries. However there are number of challenges to be met and neonatal mortality remains unacceptably high. In contrast to this neonatal care in developed nations have moved ahead of a pre-occupation to reducing the neonatal mortality only. The main reasons for this gap are poor infrastructure, resource limitations and lack of systems developed by neonatal units in the developed nations. Though this communication we explore the possibilities of application of health policies in the Australian neonatal units in developing countries.

The nurses' experience of barriers to safe practice in the neonatal intensive care unit in Thailand

OBJECTIVE

To describe barriers nurses experienced in providing safe practice in the neonatal intensive care unit and to investigate area of errors commonly affected when nurses confronted the barriers.

DESIGN

Qualitative descriptive method.

SETTING

Randomly selected 4 large neonatal intensive care units in Thailand.

PARTICIPANTS

Twenty-seven neonatal intensive care unit nurses.

MAIN OUTCOME MEASURES

A semistructured interview of the nurses' experience of neonatal intensive care unit error, factors forming barriers to safe practice, and neonatal outcome.

RESULTS

Of 245 error events, neonates were identified to suffer 126 (55.5%) adverse events. Five themes emerged as common factors obstructing nurses from incorporating safety processes into their caring roles: human susceptibility to error, system operating care weakness, problematic medical devices, poor team communication, and situational provocation. Multiple barriers were largely associated with understaffing, a sudden increase in patient acuity, multiple assignments, and an inadequate knowledge of safety in neonatal critical care, which often interacted and influenced their performance when processed to a single error occurrence.

CONCLUSION

A focus on management of the potential barriers in a system-related human error approach could prevent and intercept future errors in this vulnerable population.

Systematic review of medication errors in pediatric patients

OBJECTIVE

To systematically locate and review studies that have investigated the incidence of medication errors (MEs) in pediatric inpatients and identify common errors.

METHODS

A systematic search of studies related to MEs in children was performed using the following databases: MEDLINE (1951-April 2006), EMBASE (1966-April 2006), Pharm-line (1978-April 2006), International Pharmaceutical Abstracts (1970-April 2006), Cumulative Index to Nursing and Allied Health Literature (1982-April 2006), and British Nursing Index (1994-April 2006). Studies of the incidence and nature of MEs in pediatrics were included. The title, abstract, or full article was reviewed for relevance; any study not related to MEs in children was excluded.

RESULTS

Three methods were used to detect MEs in the studies reviewed: spontaneous reporting (n = 10), medication order or chart review (n = 14), or observation (n = 8). There was great variation in the definitions of ME used and the error rates reported. The most common type of ME was dosing error, often involving 10 times the actual dose required. Antibiotics and sedatives were the most common classes of drugs associated with MEs; these are probably among the most common drugs prescribed.

CONCLUSIONS

Interpretation of the literature was hindered by variation in definitions employed by different researchers, varying research methods and setting, and a lack of theory-based research. Overall, it would appear that our initial concern about MEs in pediatrics has been validated; however, we do not know the actual size of the problem. Further work to determine the incidence and causes of MEs in pediatrics is urgently needed, as well as evaluation of the best interventions to reduce them.

Principles and practices of medication safety in the ICU

Medication errors are a significant public health problem in United States hospitals. Patients in the ICU are at particular risk for medication errors because of the characteristics of an ICU and the nature of its patients. This article reviews the principles of medication safety and applies these principles to the ICU, and suggests safe practices to improve medication safety in the ICU.