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Medication errors in paediatric practice: insights from a continuous quality improvement approach
D G Wilson1, R G McArtney, R G Newcombe
1Congenital Heart Disease Centre Research Unit, University Hospital of Wales Healthcare NHS Trust, Heath Park, Cardiff, UK.
Unlabelled:
The objective was to assess the incidence and consequences of medication errors, highlight sources of recurrent error and institute changes in practice to prevent their recurrence. Utilising a continuous quality improvement approach, a 2-year prospective cohort study was undertaken using an adverse incident reporting scheme. A multidisciplinary committee analysed medication error reports, classifying them according to type (prescription, supply or administration), severity (serious or not serious) and clinical outcome. Changes in policy and practice were implemented to reduce the frequency of errors. There were 441 reported medication errors in the study period, during which 682 patients were admitted for 5315 inpatient days. Errors were more seven times likely to occur in the intensive care setting. Doctors accounted for 72% of errors and prescription errors doubled when new doctors joined the rotation. Most errors (68%) were detected prior to drug administration. Twenty-four serious medication errors were not detected in advance, but only 4 had overt clinical consequences. Excluding prevented errors and appropriate deviations from prescribed therapy, there were 117 actual medication errors (1/5.8 admissions, or 1/45 inpatient days). During the 2nd year of the scheme, the incidence of all reported errors, administration errors and serious errors fell, but the prescription error rate remained constant.
Conclusions:
Medication errors occurred commonly in this study, but adverse consequences were rare. The non-punitive, multidisciplinary approach to medication errors utilised in this study increased staff vigilance, highlighted sources of recurrent error, and led to changes in drug policies and staff training, which resulted in improved patient safety and quality of care.
Insights
Medication errors are common but rarely cause harm. A multidisciplinary approach improved patient safety by identifying error sources and implementing changes in drug policies and staff training.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety Research
- Medication Error Analysis
Background:
- Medication errors pose a significant risk to patient safety.
- Understanding the incidence and sources of medication errors is crucial for prevention.
- Continuous quality improvement (CQI) offers a framework for addressing healthcare-associated errors.
Purpose of the Study:
- To determine the incidence and consequences of medication errors.
- To identify recurring sources of medication errors.
- To implement practice changes to prevent future medication errors.
Main Methods:
- A 2-year prospective cohort study using an adverse incident reporting scheme.
- A multidisciplinary committee analyzed medication error reports by type, severity, and clinical outcome.
- Implemented policy and practice changes based on findings.
Main Results:
- 441 medication errors reported over 5315 inpatient days; intensive care settings had higher error rates.
- Physicians were responsible for 72% of errors; prescription errors increased with new doctor rotations.
- Serious medication errors (24) were rare, with only 4 having overt clinical consequences.
Conclusions:
- Medication errors are frequent but typically have minor clinical impact.
- A non-punitive, multidisciplinary approach enhanced staff vigilance and led to practice changes.
- Implemented interventions improved patient safety and quality of care.