Elizabeth Manias1,2,3, Noel Cranswick4,5, Fiona Newall3,5,6, Ellie Rosenfeld3, Carlye Weiner3, Allison Williams7, Ian Ck Wong8, Narelle Borrott3, Jerry Lai9, Sharon Kinney3,6. 1. School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Deakin University, Sydney, New South Wales, Australia. 2. Department of Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia. 3. Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia. 4. Department of Medicine, Clinical Pharmacology Unit, Melbourne, Victoria, Australia. 5. Murdoch Childrens Research Institute, Royal Children's Hospital, Melbourne, Victoria, Australia. 6. Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, Victoria, Australia. 7. School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia. 8. Research Department of Practice and Policy, School of Pharmacy, University College London, London, United Kingdom. 9. eResearch, Deakin University, Geelong, Victoria, Australia.
Abstract
AIM: This study aimed to examine reported medication error trends in an Australian paediatric hospital over a 5-year period and to determine the effects of person-related, environment-related and communication-related factors on the severity of medication outcomes. In particular, the focus was on the influence of changes to a hospital site and structure on the severity of medication errors. METHODS: A retrospective clinical audit was undertaken over a 5-year period of paediatric medication errors submitted to an online voluntary reporting system of an Australian, tertiary, public teaching paediatric hospital. All medication errors submitted to the online system between 1 July 2010 and 30 June 2015 were included. RESULTS: A total of 3340 medication errors was reported, which corresponded to 0.56% medication errors per combined admissions and presentations or 5.73 medication errors per 1000 bed days. The most common patient outcomes related to errors requiring monitoring or an intervention to ensure no harm occurred (n = 1631, 48.8%). A new hospital site and structure had 0.354 reduced odds of producing medication errors causing possible or probable harm (95% confidence interval 0.298-0.421, P < 0.0001). Patient and family involvement had 1.270 increased odds of identifying medication errors associated with possible or probable harm compared with those causing no harm (95% confidence interval 1.028-1.568, P = 0.027). Interrupted time series analyses showed that moving to a new hospital site and structure was associated with a reduction in reported medication errors. CONCLUSION: Encouraging child and family involvement, facilitating hospital redesign and improving communication could help to reduce the harm associated with medication errors.
AIM: This study aimed to examine reported medication error trends in an Australian paediatric hospital over a 5-year period and to determine the effects of person-related, environment-related and communication-related factors on the severity of medication outcomes. In particular, the focus was on the influence of changes to a hospital site and structure on the severity of medication errors. METHODS: A retrospective clinical audit was undertaken over a 5-year period of paediatric medication errors submitted to an online voluntary reporting system of an Australian, tertiary, public teaching paediatric hospital. All medication errors submitted to the online system between 1 July 2010 and 30 June 2015 were included. RESULTS: A total of 3340 medication errors was reported, which corresponded to 0.56% medication errors per combined admissions and presentations or 5.73 medication errors per 1000 bed days. The most common patient outcomes related to errors requiring monitoring or an intervention to ensure no harm occurred (n = 1631, 48.8%). A new hospital site and structure had 0.354 reduced odds of producing medication errors causing possible or probable harm (95% confidence interval 0.298-0.421, P < 0.0001). Patient and family involvement had 1.270 increased odds of identifying medication errors associated with possible or probable harm compared with those causing no harm (95% confidence interval 1.028-1.568, P = 0.027). Interrupted time series analyses showed that moving to a new hospital site and structure was associated with a reduction in reported medication errors. CONCLUSION: Encouraging child and family involvement, facilitating hospital redesign and improving communication could help to reduce the harm associated with medication errors.
Authors: Anwar A Alghamdi; Richard N Keers; Adam Sutherland; Andrew Carson-Stevens; Darren M Ashcroft Journal: Paediatr Drugs Date: 2021-04-08 Impact factor: 3.022
Authors: Edmundo Vázquez-Cornejo; Olga Morales-Ríos; Gabriela Hernández-Pliego; Carlo Cicero-Oneto; Juan Garduño-Espinosa Journal: PLoS One Date: 2022-03-24 Impact factor: 3.240