Disclosure of medication error in a pediatric intensive care unit

To describe the frequency medication error disclosure to the team and to the family in an oncology pediatric patients' intensive care unit.

This was a descriptive and exploratory study performed between March 1 and May 31, 2008. A medication error report form was developed and implemented, to be completed by the professionals involved in the unit's medication process.

The sample consisted of 71 forms collected over the 92 collection days. After medication error detection, the event was not reported to the pediatric intensive care unit's team in 34 (47.9%) cases. In the 37 reported to the team cases, for most of them (48.7%) the physician was the professional communicated. The event was not disclosed to the patient/family in 95.8% of medication error reports.

Although the literature recommends disclosing the errors, this is not done in the studied pediatric intensive care unit.