Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit,
Ling Li1, Tim Badgery-Parker2, Alison Merchant2
1Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia ling.li@mq.edu.au.
Insights
Incident reporting systems significantly underrepresent medication errors and harm in pediatric hospitals. Improved detection and automated monitoring are crucial for enhancing child patient safety and accurate medication error reporting.
Area of Science:
- Pediatric patient safety
- Medication error analysis
- Healthcare quality improvement
Background:
- Medication errors pose a significant risk to pediatric patients.
- Incident reporting systems are a primary method for identifying and addressing these errors.
- The accuracy and completeness of incident reporting in pediatric settings require thorough investigation.
Purpose of the Study:
- To compare medication errors identified through audits and direct observation with those reported via incident reporting systems in Australian pediatric hospitals.
- To investigate discrepancies in the types and severity of medication errors detected versus reported by healthcare staff.
- To assess the effectiveness of current incident reporting mechanisms in capturing the true incidence of medication errors and associated patient harm.
Main Methods:
- A comparative study conducted in two tertiary pediatric hospitals in Australia from 2016 to 2020.
- Prescribing errors identified via medication chart audits (7785 patient records).
- Medication administration errors identified through direct observation (5137 doses to 1530 patients), with subsequent matching to incident reports.
Main Results:
- A very low proportion of prescribing errors (3.2/1000) and potentially serious prescribing errors (11.2/1000) were reported.
- Of errors associated with actual patient harm, only 17.5% were detected and 10.0% reported.
- No medication administration errors, including those with patient harm, were reported through the incident system.
Conclusions:
- Incident reporting data do not accurately reflect the prevalence of medication errors and harm in pediatric hospitals.
- Under-detection of medication errors is a major factor contributing to low reporting rates.
- Automated, real-time monitoring systems are recommended to improve medication safety surveillance in the era of electronic health records.
Objectives:
To compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff.
Methods:
This is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records. Medication administration errors were identified from a prospective direct observational study of 5137 medication administration doses to 1530 patients. Medication errors reported to the hospitals' incident reporting system were identified and matched with errors identified at audit and observation.
Results:
Of 11 302 clinical prescribing errors identified at audit, 3.2 per 1000 errors (95% CI 2.3 to 4.4, n=36) had an incident report. Of 2224 potentially serious prescribing errors from audit, 26.1% (95% CI 24.3 to 27.9, n=580) were detected by staff and 11.2 per 1000 errors (95% CI 7.6 to 16.5, n=25) were reported to the incident system. Although the prescribing error detection rates varied between the two hospitals, there was no difference in incident reporting rates regardless of error severity. Of 40 errors associated with actual patient harm, only 7 (17.5%; 95% CI 8.7% to 31.9%) were detected by staff and 4 (10.0%; 95% CI 4.0% to 23.1%) had an incident report. None of the 2883 clinical medication administration errors observed, including 903 potentially serious errors and 144 errors associated with actual patient harm, had incident reports.
Conclusion:
Incident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring.
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