Medication errors in paediatric practice: insights from a continuous quality improvement approach

Abstract

Medication errors occurred commonly in this study, but adverse consequences were rare. The non-punitive, multidisciplinary approach to medication errors utilised in this study increased staff vigilance, highlighted sources of recurrent error, and led to changes in drug policies and staff training, which resulted in improved patient safety and quality of care.

Safety Incidents in the Primary Care Office Setting

“…48,49 Pediatric medication incidents (including their extent and methods to reduce them) have been extensively explored in the hospital setting, but less so in family practice. 43,47,[50][51][52][53][54] Our findings emphasize the importance of verification procedures and support barcode scanning of medications during dispensing and using generic medication names (rather than brand names) to reduce mistakes from inattention or distraction and communication errors. [55][56][57] …”

Systematic Steps to Diminish Multi-Fold Medication Errors in Neonates

“…20,22,23 Tenfold drug dosing errors still occur despite the use of both computerized order entry and unit-dose dispensing. 15 The nature of medication errors committed will likely change as the systems for prescribing and administering drugs evolve.…”

“…These will necessarily result in standardized modifications of multiple steps in the prescription-to-administration sequence, aimed at minimizing the frequency and consequences of prescription errors. 12,20,[24][25][26] …”

Electronic Prescribing Systems in Pediatrics: The Rationale and Functionality Requirements

“…Location-specific factors, such as the fast pace and high complexity in ICUs, are associated with a sevenfold risk of medication errors. 31 Medication errors may occur at any step in the process, from ordering (56%) to transcription (6%), dispensing (4%), and administration (34%). [32][33][34] Orders by prescribers are the most error-prone steps in the medication process, with the wrong dosage being the most common type of error.…”