RESUMO
BACKGROUND: Medication errors and adverse drug events have a significant impact on mortality and morbidity among hospitalized children, and are more likely to occur in critical care settings due to the fast-paced environment and patient vulnerability. There is no exception to this rule in our pediatric intensive care unit, a 28-bed unit at a tertiary care children's hospital in Riyadh, Saudi Arabia. PROBLEM ASSESSMENT: A medication administration error rate of 6.25-8.05/1000 patient days was reported in our unit (48 errors), taking into account only errors that reached patients. Toward improving patient safety, a project was launched to reduce medication errors. DESIGN: Multidisciplinary quality improvement team reviewed baseline data and analyzed medication errors that occurred in 2019. Five Plan-Do-Study-Act cycles were implemented. As an outcome measure, the medication error rate was monitored. RESULTS: The outcome measure of medication administration error rates was monitored quarterly. An improvement of 75% during the first quarter of 2021 to a rate of zero medication errors/1000 patient days during the first quarter of 2022. A decrease in medication errors was attributed to improved situational awareness and increased compliance with assisted technology. CONCLUSION: Medication errors can be decreased by deploying various interventions utilizing human- and technology-based approaches. When it comes to reducing medication errors in the pediatric intensive care unit, a multidisciplinary approach is paramount. IMPLICATIONS FOR CLINICAL PRACTICE: This study suggests several ways to reduce medication errors. Implementing information technology systems and involving pharmacists in medication management can help prevent errors. Enhancing teamwork, communication, and collaboration among healthcare professionals is also important. Clinical risk management strategies, nursing interventions, and adherence to medication safety guidelines are essential, especially for pediatric and neonatal populations. Considering these clinical implications can guide healthcare professionals and organizations in addressing medication errors and enhancing patient safety.
