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Medication errors in a pediatric emergency department
S M Selbst1, J A Fein, K Osterhoudt
1Division of Emergency Medicine, the Children's Hospital of Philadelphia, and University of Pennsylvania School of Medicine, USA. sselbst@nemours.org
Pediatric Emergency Care
|March 9, 1999
Summary
Medication errors in pediatric emergency departments, often due to incorrect dosing or wrong medication, are preventable. These errors can lead to adverse patient outcomes, highlighting the need for improved safety protocols.
Area of Science:
- Pediatric Emergency Medicine
- Patient Safety
- Medication Error Analysis
Background:
- Medication errors in pediatric emergency departments pose significant risks of morbidity, mortality, and litigation.
- Understanding the scope and causes of these errors is crucial for improving patient care.
Purpose of the Study:
- To investigate medication and intravenous fluid errors within a pediatric emergency department.
- To identify the causes, involved parties, and patient outcomes associated with these errors.
Main Methods:
- Retrospective chart review of incident reports over a 5-year period.
- Analysis of medication and intravenous fluid errors, including contributing factors and personnel involved.
- Classification of patient outcomes based on clinical significance.
Main Results:
- 33 incident reports involving medication or IV fluid errors were analyzed.
- Most errors occurred during evening and night shifts, with nurses and physicians jointly involved in 36% of cases.
- Incorrect medication dosage (35%) and incorrect medication (30%) were the most frequent errors; 12% of patients required additional treatment.
Conclusions:
- Common causes include incorrect patient weight recording and failure to note drug allergies.
- Similar drug names and packaging contribute to medication and IV fluid errors.
- Many medication errors in the pediatric emergency department are preventable, emphasizing the need for targeted interventions.