Abstract
Introduction Many hospitalized patients are affected by medication errors (MEs) that may cause
discomfort, harm, and even death. Especially, children are considered to be at high
risk of experiencing harm due to MEs. More insight into the prevalence, type, and
severity of harm caused by MEs could help reduce the frequency of these harmful events.
The primary objectives of our study were to establish the prevalence of different
types of MEs and the severity of harm caused by MEs in hospitalized children from
birth to 18 years of age. In addition, we investigated correlations between harmful
MEs and characteristics of the collected data from 426 hospitalized children admitted,
and the medication process.
Methods In this cross-sectional study, we identified MEs by reviewing clinical records, making
direct observations, monitoring pharmacy logs, and reviewing voluntary incident reports.
Subsequently, the MEs were classified according to type of error, medication group
and stage of the medication process. Pediatricians rated the severity of the observed
harm.
Results We collected data from 426 hospitalized children admitted during August to October
2011. A total of 322 MEs were identified, of which 39 caused patient harm. Harmful
events were mainly because of wrong time (41%). Pediatricians rated the observed harm
as minor in 77% of the incidents and significant in 23%. None of the harmful MEs resulted
in permanent harm or was considered life-threatening or fatal. Patients admitted for
a surgical procedure were at higher risk for a harmful event compared with patients
admitted for nonsurgical reasons (adjusted odds ratio 2.79, 95% confidence interval;
1.35–5.80). Nonopioid analgesics and antiemetic drugs accounted for 67% of the harmful
MEs. Harmful MEs occurred most frequently during medication prescription (28%) and
administration (62%).
Conclusion Surgical pediatric patients seem to be at high risk for harmful MEs. Although the
harm was considered minor in most cases, it still caused discomfort for the patients,
and the high prevalence is a source of concern. Interventions to prevent the MEs should
focus on the prescription and administration of nonopioid analgesics and antiemetic
drugs.
Keywords
children - harm - medication errors - prevalence - surgery
