Interventions Made by Uk Pharmacists to Minimise Risk From Paediatric Prescribing Errors

Alenezi, Sattam; Abramson, Janine; Smith, C. W.; Sammons, Helen; Conroy, Sharon

doi:10.1136/archdischild-2016-311535.65

Cited by 5 publications

(5 citation statements)

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“…Paediatric medication errors remain one of the most important patient safety issues for children and can have lethal consequences 1 2. Evidence suggests that medication errors are more likely to occur in children than in adults and may be up to three times more likely to cause harm 3–5. Voluntary incident reporting has been used to monitor medication errors and related patient safety risks in hospitals around the world 6 7.…”

Section: Introductionmentioning

confidence: 99%

“…1 2 Evidence suggests that medication errors are more likely to occur in children than in adults and may be up to three times more likely to cause harm. [3][4][5] Voluntary incident reporting has been used to monitor medication errors and related patient safety risks in hospitals around the world. 6 7 A retrospective study of medication errors in children…”

Section: Introductionmentioning

confidence: 99%

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Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system

Li,

Badgery-Parker,

Merchant

et al. 2024

BMJ Qual Saf

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ObjectivesTo compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff.MethodsThis is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records. Medication administration errors were identified from a prospective direct observational study of 5137 medication administration doses to 1530 patients. Medication errors reported to the hospitals’ incident reporting system were identified and matched with errors identified at audit and observation.ResultsOf 11 302 clinical prescribing errors identified at audit, 3.2 per 1000 errors (95% CI 2.3 to 4.4, n=36) had an incident report. Of 2224 potentially serious prescribing errors from audit, 26.1% (95% CI 24.3 to 27.9, n=580) were detected by staff and 11.2 per 1000 errors (95% CI 7.6 to 16.5, n=25) were reported to the incident system. Although the prescribing error detection rates varied between the two hospitals, there was no difference in incident reporting rates regardless of error severity. Of 40 errors associated with actual patient harm, only 7 (17.5%; 95% CI 8.7% to 31.9%) were detected by staff and 4 (10.0%; 95% CI 4.0% to 23.1%) had an incident report. None of the 2883 clinical medication administration errors observed, including 903 potentially serious errors and 144 errors associated with actual patient harm, had incident reports.ConclusionIncident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system

Li,

Badgery-Parker,

Merchant

et al. 2024

BMJ Qual Saf

View full text Add to dashboard Cite

show abstract

“…It is reassuring to see growing evidence to improve medication safety in children through identifying areas where errors occur in order to target resources and interventions, through improving education provided in relation to pediatric prescribing [14] and having pharmacists present to make interventions [10]. The research that has been done has not specifically focused on strategies to reduce errors that have the potential to cause serious harm, which may be a reason behind why harmful errors continue to occur.…”

Section: Introductionmentioning

confidence: 99%

“…A thirteen hospital site observation of documented pharmacist interventions revealed that 20.6% of 3330 patient charts had at least one medication error. The most common type of error related to incorrect dose [10].…”

Section: Introductionmentioning

confidence: 99%

“…There have been many studies that have targeted areas at which pharmacists could make interventions and prevent errors from happening in children for example preventing medication errors at the interface of care from hospital admission to discharge and post discharge [6][7][8][9], and reducing prescribing errors via pharmacist intervention [10][11]. One of the areas in patient safety that has been recently explored relates to the potential for medication discrepancies to occur across the interface of care from hospital admission to discharge.…”

Section: Introductionmentioning

confidence: 99%

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Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors

et al. 2017

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Since the publication of "To Err Is Human: Building a Safer Health System" in 1999, there has been much research conducted into the epidemiology, nature and causes of medication error in children, from prescribing and supply to administration. It is reassuring to see growing evidence to improve medication safety in children, however based on media reports, it can be seen that serious and fatal medication errors still It is important to educate future healthcare professionals of medication error and human factors to prevent these from happening.Further research is required to apply aviation's "black box" principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events.International sharing of investigations and learning are also needed.3 Key PointsMedication errors in children are complex; they may involve and affect more than just the patient and healthcare professional, as the parent may also be involved in their occurrence.Fear of litigation and lack of immunity hinders and deters healthcare professionals from voluntarily reporting medication errors.The way forward to prevent medication errors in children requires increased learning by healthcare professionals from adverse events and near misses as well as increased education on human factors. Education should also be expanded to the public to increase awareness of patient safety. Manuscript

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Case Not Closed: Prescription Errors 12 Years after Computerized Physician Order Entry Implementation

Kadmon

Pinchover

Weissbach

et al. 2017

The Journal of Pediatrics

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Interventions Made by Uk Pharmacists to Minimise Risk From Paediatric Prescribing Errors

Abstract: Prescribing errors occurred at a similar rate as in adult patients 1 but the most common type of errors was different with dosing errors most common in children. Clinical pharmacists' interventions play an important role in identifying and minimising harm from prescribing errors.

Cited by 5 publications

References 1 publication

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system

Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors

Case Not Closed: Prescription Errors 12 Years after Computerized Physician Order Entry Implementation

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