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Medication errors in hospitalised children

Authors

  • Elizabeth Manias,

    Corresponding author
    1. Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
    • Correspondence: Dr Elizabeth Manias, Melbourne School of Health Sciences, Level 6, Alan Gilbert Building, 161 Barry Street, The University of Melbourne, Parkville, Vic. 3010, Australia. Fax: +613 8344 5391; email: emanias@unimelb.edu.au

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  • Sharon Kinney,

    1. Melbourne School of Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
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  • Noel Cranswick,

    1. Department of Clinical Pharmacology, Royal Children's Hospital, Parkville, Victoria, Australia
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  • Allison Williams

    1. School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, Victoria, Australia
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  • Conflict of interest: The authors declare that they have no known conflicts of interest in relation to this paper.

Abstract

Aim

This study aims to explore the characteristics of reported medication errors occurring among children in an Australian children's hospital, and to examine the types, causes and contributing factors of medication errors.

Methods

A retrospective clinical audit was undertaken of medication errors reported to an online incident facility at an Australian children's hospital over a 4-year period.

Results

A total of 2753 medication errors were reported over the 4-year period, with an overall medication error rate of 0.31% per combined admission and presentation, or 6.58 medication errors per 1000 bed days. The two most common severity outcomes were: the medication error occurred before it reached the child (n = 749, 27.2%); and the medication error reached the child who required monitoring to confirm that it resulted in no harm (n = 1519, 55.2%). Common types of medication errors included overdose (n = 579, 21.0%) and dose omission (n = 341, 12.4%). The most common cause relating to communication involved misreading or not reading medication orders (n = 804, 29.2%). Key contributing factors involved communication relating to children's transfer across different clinical settings (n = 929, 33.7%) and the lack of following policies and procedures (n = 617, 22.4%). More than half of the reports (72.5%) were made by nurses.

Conclusion

Future research should focus on implementing and evaluating strategies aimed at reducing medication errors relating to analgesics, anti-infectives, cardiovascular agents, fluids and electrolytes and anticlotting agents, as they are consistently represented in the types of medication errors that occur. Greater attention needs to be placed on supporting health professionals in managing these medications.

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