Medication errors at Queen Sirikit National Institute of Child Health.

BACKGROUND: In the past two years, medication errors have been recognized as having been unacceptably high among hospitalized patients. OBJECTIVE: To determine the incidence and type of medication errors, severity of events, patient outcomes and categories of drugs involved in the largest pediatric hospital in Thailand over a fifteen-month-period. PATIENTS AND METHOD: Retrospective review of in-patient medication errors documented in standard reporting forms from September 2001 to November 2002. Main outcome measure was the incidence of errors reported. RESULTS: Medication errors occurred in 1 per cent of admissions (322 errors of 32,105 admissions). The most common error type was prescription error (35.40%). The majority of errors were detected and prevented before the drugs were administered (76.71%). There was only one case of permanent brain damage; no deaths occurred in the study period. The most common group of drugs involved in medication errors was antibiotics and the most common route of administration was oral. CONCLUSION: Medication errors are not uncommon. There is a need to change the behaviors of recognizing and acknowledging clinical errors, including drug errors. Careful review of errors highlights the many opportunities to change how drug errors are addressed and to make them less likely.

Treatment of Kawasaki disease using locally product intravenous immunoglobulin.

BACKGROUND: Kawasaki disease (KD) is an acute febrile illness of unknown origin. Several kinds of IVIG have been shown to be effective in the decrease of the incidence of coronary artery abnormalities (CAA) which is the most serious complication. Nowadays, the National Blood Centre, Thai Red Cross Society can manufacture IVIG from the plasma of Thai blood donors which is much cheaper than the imported intravenous immunoglobulin (IVIG's). The effectiveness of this Thai Red-Cross IVIG in Kawasaki disease has never been documented. OBJECTIVE: To determine the initial treatment response and prevalence of CAA in KD treated with a high dose (2 g/kg) of Thai Red-Cross IVIG. PATIENTS AND METHOD: All patients with a diagnosis of KD who had initial treatment with 2 g/kg of Thai Red-Cross IVIG at Queen Sirikit National Institute of Child Health from December 2001 to February 2003 were reviewed retrospectively. RESULTS: All 22 cases (100%) had good response to a single treatment with a high dose of IVIG. The only patient who did not complete the IVIG treatment had a severe reaction following the administration of the drug and needed discontinuation and intervention. During the convalescent phase, there were only 2 cases (9.09%) with CAA in the first month and 1 case (4.55%) at the 3-month follow-up. This only case with CAA at 3 months had multiple aneurysms at the left main and left anterior descending coronary arteries. No giant aneurysms were found in the present study. CONCLUSION: The efficacy of a high dose (2 g/kg) of Thai Red-Cross IVIG in Kawasaki disease is excellent. However, the severe reaction in one patient needs further surveillance.