Prescription Writing Errors in the Pediatric Emergency Department

Taylor, Bambi L; Selbst, Steven M.; Shah, Andrea E C

doi:10.1097/01.pec.0000190239.04094.72

Cited by 51 publications

(30 citation statements)

References 20 publications

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“…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%

“…Among the 17 articles reviewed, prescription errors were the most commonly reported type of medication error [Folli et al 1987;Aneja et al 1992;Wilson et al 1998;Kozer et al 2002;Fortescue et al 2003;Taylor et al 2005;Condren et al 2010;Al-Jeraisy et al 2011]. 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].…”

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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Section: Paediatricmentioning

confidence: 99%

Section: Paediatricmentioning

confidence: 99%

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

Krzyżaniak

Bajorek

2016

Therapeutic Advances in Drug Safety

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“…Some proposals to decrease the incidence of dosing errors have included having a pharmacist present on the clinical team at all times, having a satellite pharmacy, and relying on computerized systems for prescribing medications (3). Others have suggested that prescription writing taught in medical school be strictly reinforced throughout residency, and that proficiency should not be assumed (9). However, there have not been any current studies to support this latter method.…”

Section: Discussionmentioning

confidence: 93%

“…Authors have hypothesized that calculation error rates in pediatric prescriptions were contributed to by the lack of training (9). Some proposals to decrease the incidence of dosing errors have included having a pharmacist present on the clinical team at all times, having a satellite pharmacy, and relying on computerized systems for prescribing medications (3).…”

Section: Discussionmentioning

confidence: 99%

The Effects of Resident Level of Training on the Rate of Pediatric Prescription Errors in an Academic Emergency Department

Pacheco

Viscusi

Hays

et al. 2012

The Journal of Emergency Medicine

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“…There is now great emphasis placed on patient safety in PEM and other specialties. 1,3,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] This article will focus on the major sources for error in PEM and will suggest ways to reduce such errors.…”

mentioning

confidence: 99%

Preventing Medical Errors in Pediatric Emergency Medicine

Selbst¹,

Levine²,

Mull³

et al. 2004

Pediatric Emergency Care

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A 3-year-old girl received treatment in a pediatric Emergency Department (ED). Nurses in the ED had drawn up saline flush syringes from multiple dose vials of saline to clear her intravenous (IV) line. Apparently, syringes of vecuronium had been prepared for another patient who was treated before the 3-year-old arrived at the hospital. One syringe filled with vecuronium had gone unused and it was somehow mixed with the saline supplies. The syringe was hand labeled similarly to the saline syringes. As a result, a syringe containing vecuronium was used to flush the IV line of the 3-yearold girl. The child quickly became frightened and then flaccid. When all respiratory efforts ceased, she was immediately intubated and ventilated. Personnel identified the error after closer inspection of the syringes. The patient was treated supportively and fortunately suffered no permanent harm. The child's father who was present at the time of the incident reported it to the local press and the event received extensive local media attention. 1 A 5-year-old boy received ketamine for a laceration repair in the ED. The physician ordered 5 mg/kg; the patient received 50 mg/kg due to a ''math error.'' Although the patient experienced no respiratory depression, the physician chose to intubate the child as a precaution. He was discharged from the ED awake and alert 5 hours after receiving the medication. Fortunately, he suffered no long-term sequelae. 2 A 4-year-old boy was given ketamine in the ED for a fracture reduction. The order was written for 1 mg/kg of ketamine; the child received 10 mg/kg of the drug due to inadvertent use of the 100-mg/mL formulation of ketamine instead of the 10-mg/mL formulation. Two minutes after injection of the medication, the child experienced respiratory distress with oxygen desaturation to 65%. Ventilation was assisted for 9 minutes, and was then followed by normal spontaneous respirations. The patient was observed in the ED for 3 hours following receipt of the drug. He was well at discharge and suffered no long-term sequelae from the medication error. 2

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Prescription Writing Errors in the Pediatric Emergency Department

Abstract: RX errors are very common in the pediatric emergency department. Pediatric-specific experience was more influential than level of training on reducing the likelihood of error.

Cited by 51 publications

References 20 publications

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

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

The Effects of Resident Level of Training on the Rate of Pediatric Prescription Errors in an Academic Emergency Department

Preventing Medical Errors in Pediatric Emergency Medicine

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