Intercepting Medication Errors in Pediatric In-patients Using a Prescription Pre-audit Intelligent Decision System: A...

Area of Science:

• Pediatric pharmacology and medication safety.
• Health informatics and clinical decision support systems.

Background:

• Medication errors pose a significant risk in healthcare settings, impacting patient safety across all stages of drug administration.
• Prescribing errors are a common source of adverse drug events, especially in vulnerable pediatric populations.
• The need for robust systems to identify and mitigate severe prescribing errors in pediatric inpatient settings is critical.

Purpose of the Study:

• To characterize severe prescribing errors in a pediatric hospital's inpatient setting.
• To identify common error types, affected patient demographics, and involved drug classes.
• To provide recommendations for enhancing medication safety and promoting rational drug use in children.

Main Methods:

• A descriptive retrospective study was conducted at a tertiary pediatric hospital from January 2019 to December 2020.
• The Prescription Pre-audit Intelligent Decision System (PPIDS) was implemented to intercept medication orders with potential severe errors (Level 7 alerts).
• Data analyzed included patient age, department, drug classification, dosage forms, route of administration, and error type for intercepted orders.

Main Results:

• A total of 2176 severe medication orders were intercepted by the PPIDS.
• The most frequent errors involved drug dosage (35.2%), administration route (32.8%), and dose frequency (13.2%).
• Infants under one year old accounted for 53.6% of errors; neonatology (40.5%) and nephrology (15.9%) departments generated the most alerts. Injections were the most common dosage form (50.4%).

Conclusions:

• The Prescription Pre-audit Intelligent Decision System, supported by trained pharmacists, effectively validates prescriptions and enhances medication accuracy.
• This system significantly improves drug safety for hospitalized children by intercepting severe errors.
• The PPIDS represents a valuable medical service model for consideration in pediatric healthcare settings.