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A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care

Authors

  • Dorothee Niemann,

    Pharmacist
    1. Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
    2. Department of Clinical Pharmacy, University of Leipzig, Leipzig, Germany
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  • Astrid Bertsche MD,

    Senior Physician
    1. University Children's Hospital, University of Heidelberg, Heidelberg, Germany
    2. Department of Women and Child Health, Hospital for Children and Adolescents, Center for Pediatric Research, University of Leipzig, Leipzig, Germany
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  • David Meyrath,

    Pharmacist
    1. Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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  • Ellen D Koepf,

    Pharmacist
    1. Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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  • Carolin Traiser,

    Pharmacist
    1. Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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  • Katja Seebald,

    Head Nurse
    1. University Children's Hospital, University of Heidelberg, Heidelberg, Germany
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  • Claus P Schmitt MD,

    Senior Physician
    1. University Children's Hospital, University of Heidelberg, Heidelberg, Germany
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  • Georg F Hoffmann MD,

    Head of the Paediatric Center
    1. University Children's Hospital, University of Heidelberg, Heidelberg, Germany
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  • Walter E Haefeli MD,

    Head
    1. Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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  • Thilo Bertsche PhD

    Pharmacist and Head, Corresponding author
    1. Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
    2. Department of Clinical Pharmacy, University of Leipzig, Leipzig, Germany
    • Correspondence: Thilo Bertsche, Pharmacist and Head, Department of Clinical Pharmacy, University of Leipzig, Eilenburger Strasse 15a, 04317 Leipzig, Germany. Telephone: +49 3 41 9 73 66 00.

      E-mail: thilo.bertsche@medizin.uni-leipzig.de

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Abstract

Aims and objectives

To prevent medication errors in drug handling in a paediatric ward.

Background

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.

Design

A three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling.

Methods

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.

Results

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%.

Conclusion

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.

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