An evaluation of medication errors-the pediatric surgical service experience

Medication errors in pediatric patients are well recognized. The need for weight-adjusted dosing and changes in pharmacokinetic parameters make this patient population susceptible. Surgical literature discussing this topic is limited. The purpose of this study was to review the medication errors (variances) on surgical services at a major children's teaching hospital.

Medication variances occurring from January 2004 to June 2006 were reviewed. Data included service, physician, medication, type of variance, severity, explanation of variance, and time of occurrence.

There were 757 patients affected hospital-wide by a medication variance (n = 1340) for which 180 patients were on a surgical service (n = 308 variances). Residents accounted for 82% of all variances. Medication variances occurred most frequently on the general (36%) and neurosurgery services (20.5%). Seventy-one percent of the variances were classified as potential to cause harm but were corrected before reaching the patient. Five percent of variances reached the patient and caused temporary harm. Incorrect dose accounted for 72% of variances, followed by incorrect dosage form or omission in 5%, and missed allergies in 4%. Antibiotics were implicated in 31% of variances. Most errors occurred during daytime work hours.

Our data show that most of prescribing medication variances never reached the patient and were recognized by pharmacy or nursing. There is a continued need to enhance local education (resident) using a service-specific clinical pharmacist to focus on appropriate dosing especially in regard to antibiotics. Computerized physician order entry when implemented will help to minimize some of these errors. However, in the interim, a service-specific medication dosing card is being implemented. Quarterly service-specific data will be incorporated into the resident/fellow clinical conferences to minimize future variance occurrences.