Analysis of medication prescribing errors in critically ill children

Area of Science:

• Pediatric Intensive Care
• Clinical Pharmacy
• Patient Safety

Background:

• Medication prescribing errors (MPEs) are a frequent type of medication error, with higher incidence in pediatric populations compared to adults.
• Risk factors for MPEs include specific medication classes, prolonged PICU stays, and mechanical ventilation.
• Analyzing the interplay between frequent prescribing errors and their severity is crucial for understanding patient risk.

Purpose of the Study:

• To prospectively identify and quantify medication prescribing errors in critically ill children.
• To determine the frequency, type, and severity of MPEs within a pediatric intensive care unit (PICU).
• To provide data that can inform strategies for error reduction and improved patient safety.

Main Methods:

• A prospective observational study was conducted in a PICU.
• A clinical pharmacist prospectively identified medication prescribing errors.
• A total of 1129 medication orders were analyzed.

Main Results:

• An overall medication prescribing error rate of 14% was observed (151 errors out of 1129 orders).
• Medication groups with the highest error rates included antihypertensives, antimycotics, and nasal preparation drugs (50% each).
• 70% of MPEs (104 errors) required intervention or resulted in patient harm, representing 9% of all medication orders.

Conclusions:

• The study identified a significant rate of medication prescribing errors in a PICU setting.
• Specific medication classes were associated with a higher proportion of errors.
• These findings can guide interventions to reduce MPEs and enhance patient safety in pediatric intensive care.