Identifying and assessing potential harm of medication errors and potentially unsafe medication practices in paediatric hospital settings: a field study.

BACKGROUND: Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. METHODS: A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss' Kappa. RESULTS: A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8%. No actual harm to patients was observed during the study. Raters assessed the potential harm of 318 unique MEs and PUMPs. Only slight agreement was found (Kappa = 0.26-0.33). A 4-hour delay in the administration of intravenous cefuroxime received the highest harm score. Observations involving no information during prescribing and variations in medication preparation were considered potentially fatal for medications such as digoxin, morphine, enoxaparin and insulin. CONCLUSIONS: MEs and potentially unsafe practices and conditions may affect medication safety of hospitalized children. However, observed MEs did not result in any harm. The agreement among raters assessing the potential harm of observations was low. Alternative methods to determine the clinical relevance of errors are needed.

Qualitative exploration of practices to prevent medication errors in neonatal intensive care units: a focus group study.

BACKGROUND: Medication errors (MEs) in neonates are frequent and associated with increased potential for harm compared with adults. The effect of learning from reported MEs is potentially lacking due to underreporting, lack of feedback and missing actions to improve medication safety. A new approach involving positive recognition of current and future strategies may facilitate greater exploration of how to improve medication safety in neonates. We aimed to explore current and potential future practices to prevent MEs in neonatal intensive care units (NICUs). METHODS: Focus group interviews of physicians and nurses were conducted at three Danish NICUs. Participants were included if they had at least 1 month of working experience and provided direct patient care. A semistructured interview guide involving three questions was used: (a) how do you feel about discussing prevention of MEs? (b) how do you currently prevent MEs from occurring? and (c) how can we become better at preventing MEs in the future? Content analysis was used to identify themes in the interviews. RESULTS: Participants commented that MEs still occur and that action must be taken to improve medication safety. Current practices to prevent MEs involved technology, procedures, education, skills and hospital pharmacy services. Potential future practices to prevent MEs included customizing the computerized physician order entry systems to support optimal prescribing, standardizing the double-check process, training of calculation skills and teamwork and increased use of hospital pharmacy services. CONCLUSIONS: Several current and potential future practices to reduce MEs in NICUs were identified, highlighting the complexity of MEs. Our findings support an interdisciplinary multifaceted intervention involving both technical and nontechnical elements to improve medication safety in NICUs.

Likelihood of reporting medication errors in hospitalized children: a survey of nurses and physicians.

BACKGROUND: Hospitalized children are at risk of medication errors (MEs) due to complex dosage calculations and preparations. Incident reporting systems may facilitate prevention of MEs but underreporting potentially undermines this system. We aimed to examine whether scenarios involving medications should be reported to a national mandatory incident reporting system and the likelihood of self- and peer-reporting these scenarios among paediatric nurses and physicians. METHODS: Participants' reporting of MEs was explored through a questionnaire involving 20 medication scenarios. The scenarios represented different steps in the medication process, types of error, patient outcomes and medications. Reporting rates and odds ratios with 95% confidence interval [OR, (95% CI)] were calculated. Barriers to and enablers of reporting were identified through content analysis of participants' comments. RESULTS: The response rate was 42% (291/689). Overall, 61% of participants reported that scenarios should be reported. The likelihood of reporting was 60% for self-reporting and 37% for peer-reporting. Nurses versus physicians, and healthcare professionals with versus without patient safety responsibilities assessed to a larger extent that the scenarios should be reported [OR = 1.34 (1.05-1.70) and OR = 1.41 (1.12-1.78), respectively]; were more likely to self-report, [OR = 2.81 (1.71-4.62) and OR = 2.93 (1.47-5.84), respectively]; and were more likely to peer-report [OR = 1.89 (1.36-2.63) and OR = 3.61 (2.57-5.06), respectively].Healthcare professionals with versus without management responsibilities were more likely to peer-report [OR = 5.16 (3.44-7.72)]. Participants reported that scenarios resulting in actual injury or incidents considered to have a learning potential should be reported. CONCLUSION: The likelihood of underreporting scenarios was high among paediatric nurses and physicians. Nurses and staff with patient safety responsibilities were more likely to assess that scenarios should be reported and to report. Incidents with actual injury or learning potential were more likely to be reported. The potential for improving reporting rates involving MEs seems high.

Medication errors in pediatric inpatients: a study based on a national mandatory reporting system.

The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010-2014. We included reports from public hospitals on patients aged 0-17 years and categorized by reporters as medication-related. Reports from psychiatric wards and outpatient clinics were excluded. A ME was defined as any medication-related error occurring in the medication process whether harmful or not. MEs were categorized as harmful if they resulted in actual harm or interventions to prevent harm. MEs were further categorized according to occurrence in the medication process, type of error, and the medicines involved. A total of 2071 MEs including 487 harmful MEs were identified. Most MEs occurred during prescribing (40.8%), followed by dispensing (38.7%). Harmful MEs occurred mainly during dispensing (40.3%). Dosing errors were the most reported type of error, 47.7% of all MEs and 45.4% of harmful MEs. Antibiotics and analgesics were the most frequently reported medication classes. Common medicines associated with MEs included morphine, paracetamol, and gentamicin. MEs caused no harm (74.9%), mild (11.7%), moderate (10.5%), or severe harm (1.3%), but none were lethal. CONCLUSION: MEs in hospitalized children occur in all medication processes and mainly involve dosing errors. Strategies should be developed to prevent MEs as these still threaten medication safety in pediatric inpatients. What is known: • Hospitalized children are more likely to experience medication errors than adults. • Voluntary national and local reporting and learning systems have previously been used to describe the nature and types of medication errors. What is new: • Medication errors in hospitalized children occur in all steps of the medication process, most frequently involving dosing errors and most commonly involving morphine, paracetamol, and gentamicin. • Of the medication errors, 1.3% cause severe harm, but no fatal errors were reported.