Developing a process to measure actual harm from medication errors in paediatric inpatients: From design to...

Area of Science:

• Pediatric patient safety
• Medication error analysis
• Healthcare quality improvement

Background:

• Medication errors pose significant risks, yet data on actual harm are scarce.
• Existing methods for assessing harm lack detailed descriptions, hindering reproducibility.
• There's a need for a robust process to evaluate real-world harm from medication errors in pediatric settings.

Purpose of the Study:

• To design and implement a novel process for assessing actual harm from medication errors.
• To evaluate the effectiveness of this process in a tertiary pediatric hospital.
• To provide a reproducible method for harm assessment in pediatric inpatient care.

Main Methods:

• Retrospective review of 26,369 prescribing orders and direct observation of 5,137 medication administrations.
• Assigning potential harm severity ratings (5-point scale) to all identified errors.
• Multidisciplinary panels reviewed high-potential harm cases to determine actual harm, causality, and confidence levels.

Main Results:

• 28 multidisciplinary panels reviewed 566 cases (173 prescribing, 393 administration errors).
• Actual harm was identified in 89 cases (22 prescribing, 67 administration).
• Eight cases of serious harm (1 prescribing, 7 administration) were found; no severe harm cases occurred.

Conclusions:

• The developed harm assessment process offers a systematic approach to determining actual harm from medication errors.
• The multidisciplinary panel composition was crucial for considering clinical, therapeutic, and contextual factors.
• This methodology enhances the evaluation of medication errors' real-world impact in pediatric care.