Prevalence of errors in a pediatric hospital medication system: implications for error proofing

Area of Science:

• Pediatric Healthcare
• Medication Safety Systems
• Health Informatics

Background:

• Medication systems are complex, involving multiple steps from order to administration.
• Identifying and categorizing errors is crucial for improving patient safety.
• Previous research indicates medication errors are a significant concern in healthcare settings.

Purpose of the Study:

• To determine the prevalence and types of errors within a pediatric teaching hospital's medication system.
• To identify where errors occur in the medication process (order, preparation, administration).
• To provide data for developing strategies to "error-proof" the medication system.

Main Methods:

• A broad definition of error was used, encompassing deviations from order to dose administration.
• Analysis of 3,312 medication orders over 669 patient-days, totaling 11,978 doses.
• Errors were categorized as intercepted or administration errors, and as primary or supporting activity errors.

Main Results:

• A total of 784 errors were identified.
• The vast majority (98%) of errors were intercepted before reaching the patient.
• A significant majority of errors (71%) occurred in supporting activities rather than primary prescribing or preparation activities.

Conclusions:

• Medication errors are inherent in complex hospital systems but are often caught by existing safeguards.
• Intercepting errors requires substantial effort and contributes to process complexity.
• Future error-proofing efforts must differentiate between primary and supporting activity errors for effectiveness.