Frequency of Pediatric Medication Administration Errors and Contributing Factors

Özkan, Suzan; Kocaman, Gülseren; Öztürk, Candan; Seren, Seyda

doi:10.1097/ncq.0b013e3182031006

Cited by 41 publications

(38 citation statements)

References 23 publications

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“…Most of them were related to dose as well as the preparation of wrong medications. According to the results of qualitative studies which examined the reasons of errors, interruptions ranked at the top of the factors leading to errors (1,15,16). In the study of Westbrook et al (3), which was the first study to assess the relationship between interruptions and medication errors, it was determined that the interruption frequency increases the severity of medication error.…”

Section: Discussionmentioning

confidence: 99%

“…This study was a part of the project which observed the errors that were made during the pediatric medication administration process (15). In this descriptive study, observation method was used in an attempt to determine the frequency and reasons of interruptions experienced by nurses during the preparation and administration of pediatric medications.…”

Section: Methodsmentioning

confidence: 99%

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Interruptions During Pediatric Medication Preparation and Administration

Özkan¹,

Kocaman²,

Öztürk³

2016

jpr

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Interruptions During Pediatric Medication Preparation and Administration

Özkan¹,

Kocaman²,

Öztürk³

2016

jpr

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“…The administration of incorrect doses was the most commonly reported error, and specifically related to tenfold overdoses [Wilson et al 1998;Frey et al 2000Frey et al , 2002Ross et al 2000;Kozer et al 2002;Fortescue et al 2003;Otero et al 2008;Wong et al 2009;Ghaleb et al 2010;Belela et al 2011;Ozkan et al 2011]. A Canadian retrospective cohort study reported that children were at a greater risk of being administered tenfold overdoses than adults because the volume of a dose that was ten-times the normal range for paediatric patients would still look like a relatively small volume of stock solution [Kozer et al 2002].…”

Section: Paediatricmentioning

confidence: 99%

“…Medication errors occurred frequently within the administration phase, comprising 12.8-73% of total reported errors [Frey et al 2002;Ghaleb et al 2010;Belela et al 2011;Ozkan et al 2011].…”

Section: Paediatricmentioning

confidence: 99%

“…Accounting for 10-74% of total error reports, these types of errors were most commonly identified via retrospective and prospective reviews of patient charts and medication incident reports [Folli et al 1987;Aneja et al 1992;Wilson et al 1998;Frey et al 2000Frey et al , 2002Ross et al 2000;Kozer et al 2002;Fortescue et al 2003;Taylor et al 2005;Otero et al 2008;Condren et al 2010;Wong et al 2009;Ghaleb et al 2010;Al-Jeraisy et al 2011;Belela et al 2011;Ozkan et al 2011;Manias et al 2014]. Overall, dosing errors were the most common type reported, making up 82.6% of prescribing errors [Folli et al 1987;Aneja et al 1992;Wilson et al 1998;Kozer et al 2002;Fortescue et al 2003;Wong et al 2009;Al-Jeraisy et al 2011].…”

Section: Paediatricmentioning

confidence: 99%

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Medication safety in neonatal care: a review of medication errors among neonates

Krzyżaniak

Bajorek

2016

Therapeutic Advances in Drug Safety

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Objective: The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum. Method: In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients. Results: A total of 58 articles were reviewed. Medication errors were well documented in each patient group. Overall, prescribing and administration errors were most commonly identified across each population, and mostly related to errors in dosing. Errors due to patient misidentification and overdosing were particularly prevalent in neonates, with 47% of administration errors involving at least tenfold overdoses. Unique errors were identified in elderly patients, comprising duplication of therapy and unnecessary prescribing of medicines. Overall, the medicines most frequently identified with error across each patient group included: heparin, antibiotics, insulin, morphine and parenteral nutrition. While neonatal patients experience the same types of medication errors as other hospitalized patients, the medication-use process within this group is more complex and has greater consequences resulting from error. Suggested strategies to help overcome medication error most commonly involved the integration of a clinical pharmacist into the treating team. Conclusion: This review highlights that each step of the medication-use process is prone to error across the age spectrum. Further research is required to develop targeted strategies relevant to specific patient groups that integrate key pharmacy services into wards.

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The Effects of Clinical Task Interruptions on Subsequent Performance of a Medication Pre-Administration Task

Williams

Morgan

Christopher

et al. 2019

Advances in Intelligent Systems and Computing

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There is a surge of research exploring the role of task interruptions in the manifestation of primary task errors both in controlled experimental settings, and safety critical workplaces such as healthcare. Despite such research providing valuable insights into the disruptive properties of task interruption, and, the importance of considering the likely disruptive consequences of clinical task interruptions in healthcare environments, there is an urgent need for an approach that best mimics complex working environments such as healthcare, whilst allowing better control over experimental variables with minimal constraints. We propose that this can be achieved with ecologically sensitive experimental tasks designed to have high levels of experimental control so that theoretical as well as practical parameters and factors can be tested. We developed a theoretically and ecologically informed procedural memory-based task-the CAMROSE Medication Pre-Administration Task. Results revealed significantly more sequence errors were made on low, moderate and high complex conditions compared to no interruption condition. There was no significant difference in non-sequence errors. Findings reveal the importance of developing ecologically valid tasks to explore non-observable characteristics of clinical task interruptions. Both theoretical and possible practical implications are discussed.

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Frequency of Pediatric Medication Administration Errors and Contributing Factors

Cited by 41 publications

References 23 publications

Interruptions During Pediatric Medication Preparation and Administration

Interruptions During Pediatric Medication Preparation and Administration

Medication safety in neonatal care: a review of medication errors among neonates

The Effects of Clinical Task Interruptions on Subsequent Performance of a Medication Pre-Administration Task

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