“Medication errors in paediatric practice: insights from a continuous quality improvement approach.”
This study investigates the prevalence and the effects of medication errors, emphasises the causes of repeated errors, and establishes changes in practice to thwart their recurrence.
Reports on medication errors were examined by a multidisciplinary committee. The team classified them in terms of type (prescription, supply or administration), severity (serious or not serious) and clinical outcome. To lessen the number of errors, policy and practice changes were instituted.
During the 2 year study period, 441 medication errors were reported. Within this period, 682 patients were admitted for 5315 in-patient days. The intensive care setting had more than 7 times the likelihood of errors. Seventy-two percent of the errors were made by doctors and doubled when new doctors joined the rotation. Majority of the errors (68%) were noticed prior to the administration of the drug. Only 4 medication errors resulted to noticeable clinical consequences among 24 undetected serious errors. One hundred seventeen medication errors, not including detected errors, were documented (1/5.8 admissions, or 1/45 inpatient days). Prevalence of administration errors fell during the 2nd year of the study but the number of prescription errors stayed the same.
This study emphasises the prevalence of medication errors in medical practice.