Rikke Mie Rishoej1, Anna Birna Almarsdóttir2, Henrik Thybo Christesen3,4, Jesper Hallas5, Lene Juel Kjeldsen6. 1. Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 19.2, 5000, Odense, Denmark. rmrishoj@health.sdu.dk. 2. Section of Social and Clinical Pharmacy, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark. 3. Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark. 4. Department of Clinical Research, University of Southern Denmark, Odense, Denmark. 5. Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 19.2, 5000, Odense, Denmark. 6. Amgros I/S, Copenhagen, Denmark.
Abstract
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.
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.
Entities:
Keywords:
Hospitalized children; Medication errors; Reporting and learning systems
Authors: Jerome K Wang; Nicole S Herzog; Rainu Kaushal; Christine Park; Carol Mochizuki; Scott R Weingarten Journal: Pediatrics Date: 2007-01 Impact factor: 7.124
Authors: Y M Arabi; S M Al Owais; K Al-Attas; A Alamry; K AlZahrani; B Baig; D White; A M Deeb; H D Al-Dozri; S Haddad; H M Tamim; S Taher Journal: Anaesth Intensive Care Date: 2016-03 Impact factor: 1.669
Authors: Maisoon Abdullah Ghaleb; Nick Barber; Bryony D Franklin; Vincent W S Yeung; Zahra F Khaki; Ian C K Wong Journal: Ann Pharmacother Date: 2006-09-19 Impact factor: 3.154
Authors: James A Taylor; Dena Brownstein; Dimitri A Christakis; Susan Blackburn; Thomas P Strandjord; Eileen J Klein; Jaleh Shafii Journal: Pediatrics Date: 2004-09 Impact factor: 7.124
Authors: Alaa M Hammad; Walid Al-Qerem; Fawaz Alasmari; Jonathan Ling; Raghda Qarqaz; Hakam Alaqabani Journal: Int J Environ Res Public Health Date: 2022-06-12 Impact factor: 4.614