A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care
Version of Record online: 3 JUN 2014
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing
Volume 24, Issue 1-2, pages 101–114, January 2015
How to Cite
Niemann, D., Bertsche, A., Meyrath, D., Koepf, E. D., Traiser, C., Seebald, K., Schmitt, C. P., Hoffmann, G. F., Haefeli, W. E. and Bertsche, T. (2015), A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care. Journal of Clinical Nursing, 24: 101–114. doi: 10.1111/jocn.12592
- Issue online: 23 DEC 2014
- Version of Record online: 3 JUN 2014
- Manuscript Accepted: 14 FEB 2014
- University of Heidelberg
- Free State of Saxony and the Federal State of Baden-Wuerttemberg
- German National Academic Foundation
- causes of errors;
- drug handling;
- intervention studies;
- medication error;
- quality of health care
Aims and objectives
To prevent medication errors in drug handling in a paediatric ward.
One in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce.
A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling.
After approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors.
The number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct ‘volume of solvent for IV drugs’ from 49–25%.
Paediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes.
Relevance to clinical practice
Worldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings.