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Intercepting Medication Errors in Pediatric In-patients Using a Prescription Pre-audit Intelligent Decision System: A
Guangfei Wang1, Feng Zheng1, Guiyao Zhang2
1Department of Clinical Pharmacy, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, 201102, China.
Insights
A system successfully intercepted severe medication errors in a pediatric hospital, particularly in infants and concerning drug dosage and administration routes. This highlights the system
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.
Objectives:
Medication errors can happen at any phase of the medication process at health care settings. The objective of this study is to identify the characteristics of severe prescribing errors at a pediatric hospital in the inpatient setting and to provide recommendations to improve medication safety and rational drug use.
Methods:
This descriptive retrospective study was conducted at a tertiary pediatric hospital using data collected from Jan. 1st, 2019 to Dec. 31st, 2020. During this period, the Prescription Pre-audit Intelligent Decision System was implemented. Medication orders with potential severe errors would trigger a Level 7 alert and would be intercepted before it reached the pharmacy. Trained pharmacists maintained the system and facilitated decision making when necessary. For each order intercepted by the system the following patient details were recorded and analyzed: patient age, patient's department, drug classification, dosage forms, route of administration, and the type of error.
Results:
A total of 2176 Level 7 medication orders were intercepted. The most common errors were associated with drug dosage, administration route, and dose frequency, accounting for 35.2%, 32.8% and 13.2%, respectively. Of all the intercepted oerrors. 53.6% occurred in infants aged < 1 year. Administration routes involved were mainly intravenous, oral and external use drugs. Most alerts came from the neonatology department and constituted 40.5% of the total alerts, followed by the nephrology department 15.9% and pediatric intensive care unit (PICU) 11.3%. As to dosage forms, injections accounted for 50.4% of alerts, with 21.3% attributable to topical solutions, 9.1% to tablets, and 5.7% to inhalation. Anti-infective agents were the most common therapeutic drugs prescribed with errors.
Conclusions:
The Prescription Pre-audit Intelligent Decision System, with the supervision of trained pharmacists can validate prescriptions, increase prescription accuracy, and improve drug safety for hospitalized children. It is a medical service model worthy of consideration.
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