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A Novel Approach for the Administration of Medications and Fluids in Emergency Scenarios and Settings
Published on: November 9, 2016
Reported medication events in a paediatric emergency research network: sharing to improve patient safety
Kathy N Shaw1, Kathleen A Lillis, Richard M Ruddy
1Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-1902, USA. Shaw@email.chop.edu
Insights
Paediatric medication errors in emergency departments (EDs) were analyzed from incident reports. Most errors stemmed from human factors, with few resulting in severe harm, indicating areas for intervention.
Area of Science:
- Pediatric Emergency Medicine
- Patient Safety
- Medication Error Analysis
Background:
- Medication errors are a significant cause of preventable harm in pediatric emergency departments (EDs).
- Voluntary incident reporting (IR) systems are common in hospitals but often lack external data sharing.
- Analysis of 597 pediatric medication events (MEs) from 18 EDs between 2007-2008.
Purpose of the Study:
- To describe the analysis of pediatric medication events (MEs) reported in emergency departments (EDs).
- To identify common medication categories, error types, and contributing human factors.
- To understand the outcomes of medication errors and adverse reactions in pediatric ED settings.
Main Methods:
- Confidential, deidentified incident reports (IRs) were collected from 18 pediatric EDs.
- Medication events (MEs) were independently categorized by two investigators, with discrepancies resolved by consensus.
- Analysis focused on medication errors, including dose errors, look-alike/sound-alike issues, and contributing human factors.
Main Results:
- Medication errors constituted 94% of the 597 reported MEs.
- Incorrect medication doses were frequently linked to incorrect weight, duplicate dosing, and miscalculation.
- Human factors, such as procedural failures and communication issues, contributed to 85% of reports; 13% of MEs resulted in patient harm.
Conclusions:
- Incident reporting systems provide valuable data on pediatric medication errors in EDs.
- Analysis identified key medication categories and human factors contributing to errors.
- Findings suggest targeted interventions are needed to reduce pediatric medication errors and improve systems issues.
Objective:
Medication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little external reporting or sharing of this information across institutions. We describe the analysis of paediatric medication events (ME) reported in 18 EDs in a paediatric research network in 2007-2008.
Methods:
Confidential, deidentified incident reports (IRs) were collected, and MEs were independently categorised by two investigators. Discordant responses were resolved by consensus.
Results:
MEs (597) accounted for 19% of all IRs, with reporting rates varying 25-fold across sites. Anti-infective agents were the most commonly reported, followed by analgesics, intravenous fluids and respiratory medicines. Of the 597 MEs, 94% were medication errors and 6% adverse reactions; further analyses are reported for medication errors. Incorrect medication doses were related to incorrect weight (20%), duplicate doses (21%), and miscalculation (22%). Look-alike/sound-alike MEs were 36% of incorrect medications. Human factors contributed in 85% of reports: failure to follow established procedures (41%), calculation (13%) or judgment (12%) errors, and communication failures (20%). Outcomes were: no deaths or permanent disability, 13% patient harm, 47% reached patient (no harm), 30% near miss or unsafe conditions, and 9% unknown.
Conclusions:
ME reporting by the system revealed valuable data across sites on medication categories and potential human factors. Harm was infrequently reported. Our analyses identify trends and latent systems issues, suggesting areas for future interventions to reduce paediatric ED medication errors.
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