Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study

Abstract

This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting. Patients and Methods: We performed a 10-year retrospective study (January 2011-December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome. Results: In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour-14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs. Conclusion: Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.

Handwritten prescription practices in a public hospital in Uasin Gishu County, Kenya: a best practice implementation project

“…This increases the economic burden on both the patient and the health care system, and increases morbidity and mortality. 16 It may also result in medico-legal issues for health providers and health institutions. 25 The current project was conducted in the outpatient department of Uasin Gishu County Referral Hospital, Kenya, a public hospital situated in an urban area with a population of approximately 1.16 million.…”

“…Medication errors are a common global occurrence 16 . Although under-reported, the prevalence of prescription errors in South East Asia 16 and Africa is high 14,15,17,18 .…”

“…Medication errors are a common global occurrence 16 . Although under-reported, the prevalence of prescription errors in South East Asia 16 and Africa is high 14,15,17,18 . A study conducted in South Africa indicated that pharmacists could not read a quarter of the prescriptions and most of the prescriptions lacked the essential features 4 .…”

“…The consequences of prescription errors include unnecessary hospitalization from adverse effects because of the prescribed medicines. This increases the economic burden on both the patient and the health care system, and increases morbidity and mortality 16 . It may also result in medico-legal issues for health providers and health institutions 25…”

Medication Errors in Pediatric Emergency Departments

“…The impact of medication errors in the P-ED can be serious, 10 necessitating a comprehensive analysis of the existing literature. Currently, there is a lack of comprehensive synthesis and analysis in this area.…”