Prevalence of Medications Errors and Factors of Harmful Errors in Neonates and Paediatrics at Tertiary and Paediatric Hospitals: A Multicenter Study
DOI:
https://doi.org/10.54536/ajlsi.v3i1.2729Keywords:
Medication Error, Neonatal, Prescribing Error, Prevalence, PediatricsAbstract
Medication errors (ME) are human mistakes that may occur during drug use, prescribing administration or monitoring. This study aimed to determine the Prevalence of MEs among pediatric patients receiving tertiary treatment in pediatric speciality hospitals and describe their patterns and causes. Three institutions participated in a multicenter retrospective analysis. Reports of all MEs involving paediatrics aged ≤13 years who were hospitalised or visited the Emergency Department or outpatient clinics were reviewed 1 January 2019 - 31 December 2019. The National Coordinating Council for Medication Error Reporting and Prevention classification was used to categorise MEs and to define PRME (category CI) and patient–harming MEs (category EI). A retrospective study was conducted with a total of 318 MEs reported, with an overall prevalence of 0.9 per 1,000 patients. The Prevalence was markedly lower in the CHT (0.35 / 1,000 patients) than in KAMC and KFSH&RC (1.73 and 3.5). The highest rate of MEs was observed in admitted wards (14.69 / 1,000 patients). Most commonly, MEs occurred at the prescribing stage (81.1%), were caused by a physician (83.3%), and were discovered by the pharmacist (85.5%). Improper medication dosage (34.0%), frequency (14.2%), and duration (10.4%) were the three most common forms of MEs. Paediatric inpatient treatment has a significant frequency of MEs, accounting for 24% of hospitalisations. The ME may not get to the patient if independent double-check prescriptions, accurate medication reconciliation of new prescriptions against the previously prescribed, and improved medicine labelling and packaging techniques are used.
Downloads
References
A Truter, N. S. a. J. C. M. (2017). Identifying medication errors in the neonatal intensive care unit and paediatric wards using a medication error checklist at a tertiary academic hospital in Gauteng, South Africa. South African Journal of Child Health, 11(1).
Abuelsoud, N. (2019). Pharmacy quality improvement project to enhance the medication management process in pediatric patients. Irish Journal of Medical Science (1971 -), 188(2), 591-600. https://doi.org/10.1007/s11845-018-1860-8
Al-Jeraisy, M. I., Alanazi, M. Q., & Abolfotouh, M. A. (2011). Medication prescribing errors in a pediatric inpatient tertiary care setting in Saudi Arabia. BMC Research Notes, 4(1), 294. https://doi.org/10.1186/1756-0500-4-294
Alghamdi, A. A., Keers, R. N., Sutherland, A., & Ashcroft, D. M. (2019). Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review. Drug safety, 42, 1423-1436.
Alqenae, F. A., Steinke, D., & Keers, R. N. (2020). Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review. Drug safety, 43(6), 517-537. https://doi.org/10.1007/s40264-020-00918-3
Antonucci, R., & Porcella, A. (2014). Preventing medication errors in neonatology: Is it a dream? World J Clin Pediatr, 3(3), 37-44. https://doi.org/10.5409/wjcp.v3.i3.37
Bharathi, B. P., Raj, J. P., Saldanha, K., Rao, P. S., & Devi, D. P. (2020). Medication errors in neonatal intensive care unit of a tertiary care hospital in South India: a prospective observational study. Indian Journal of Pharmacology, 52(4), 260-265. https://doi.org/10.4103/ijp.IJP_611_19
Brennan-Bourdon, L. M., Vázquez-Alvarez, A. O., Gallegos-Llamas, J., Koninckx-Cañada, M., Marco-Garbayo, J. L., & Huerta-Olvera, S. G. (2020). A study of medication errors during the prescription stage in the pediatric critical care services of a secondary-tertiary level public hospital. BMC Pediatrics, 20(1), 549. https://doi.org/10.1186/s12887-020-02442-w
Dedefo, M. G., Mitike, A. H., & Angamo, M. T. (2016). Incidence and determinants of medication errors and adverse drug events among hospitalized children in West Ethiopia. BMC Pediatrics, 16(1), 81. https://doi.org/10.1186/s12887-016-0619-5
Devine, E. B., W.-N. J., Lawless, N. M., et al. (2005). Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors. 2.
Devine, E. B., Wilson-Norton, J. L., Lawless, N. M., Hazlet, T. K., Hansen, R., Kelly, K., ... & Wong, C. (2005). Preparing for ambulatory computerized prescriber order entry by evaluating preimplementation medication errors. Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology).
Escrivá Gracia, J., Brage Serrano, R., & Fernández Garrido, J. (2019). Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC Health Services Research, 19(1), 640. https://doi.org/10.1186/s12913-019-4481-7
Fernández-Llamazares, C. M., Calleja-Hernandez, M. A., Manrique-Rodriguez, S., Pérez-Sanz, C., Duran-García, E., & Sanjurjo-Saez, M. (2012). Impact of clinical pharmacist interventions in reducing paediatric prescribing errors. Archives of Disease in Childhood, 97(6), 564-568. https://doi.org/10.1136/archdischild-2011-301239
Hmedat, B., Alnjajrah, E., Manasrah, I., Radwan, I., & Alkhatib, M. (2017). Medication dosing errors and associated factors in hospitalized pediatric patients from the South Area of the West Bank-Palestine. Saudi pharmaceutical journal, 25(6), 857-860.
Hussain, S., Nori, D., & Baban, T. (2014). Medication errors in pediatric hospitals. American Journal of Pharmacy and Pharmacology, 1, 56-61.
Impicciatore, P., Choonara, I., Clarkson, A., Provasi, D., Pandolfini, C., & Bonati, M. (2001). Incidence of adverse drug reactions in paediatric in/out‐patients: a systematic review and meta‐analysis of prospective studies. British journal of clinical pharmacology, 52(1), 77-83.
Izadpanah, F., Nikfar, S., Bakhshi Imcheh, F., Amini, M., & Zargaran, M. (2018). Assessment of Frequency and Causes of Medication Errors in Pediatrics and Emergency Wards of Teaching Hospitals Affiliated to Tehran University of Medical Sciences (24 Hospitals). J Med Life, 11(4), 299-305. https://doi.org/10.25122/jml-2018-0046
Jennifer L Costello 1, D. L. T., Timothy S Yeh. (2007). Effects of a pharmacist-led pediatrics medication safety team on medication-error reporting. https://doi.org/10.2146/ajhp060296.
Kaushal, R., Bates, D. W., Landrigan, C., McKenna, K. J., Clapp, M. D., Federico, F., & Goldmann, D. A. (2001). Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA, 285(16), 2114-2120. https://doi.org/10.1001/jama.285.16.2114
Khaemba, C. N. (2014). Incidence and determinants of medication errors Among paediatric in-patients at Kisii level 5 hospital University of Nairobi].
Khayam, M. U. (2015). Medication errors assessment and prevention by a clinical pharmacist in pediatric wards of RMI Hospital Peshawar, KPK-Pakistan. Ann. Pak. Inst. Med. Sci, 11(3), 124-129.
Krzyzaniak, N., & Bajorek, B. (2016). Medication safety in neonatal care: a review of medication errors among neonates. Therapeutic advances in drug safety, 7(3), 102-119.
Laatikainen, O., Sneck, S., & Turpeinen, M. (2022). Medication-related adverse events in health care—What have we learned? A narrative overview of the current knowledge. European Journal of Clinical Pharmacology, 1-12.
Liu, K. W., Shih, Y. F., Chiang, Y. J., Chen, L. J., Lee, C. H., Chen, H. N., Chen, J. Y., & Hsiao, C. C. (2023). Reducing Medication Errors in Children’s Hospitals. J Patient Saf, 19(3), 151-157. https://doi.org/10.1097/pts.0000000000001087
Maaskant, J. M., Vermeulen, H., Apampa, B., Fernando, B., Ghaleb, M. A., Neubert, A., Thayyil, S., & Soe, A. (2015). Interventions for reducing medication errors in children in hospital. Cochrane Database of Systematic Reviews(3).
MERP, N. (1998). National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). Taxonomy of Medication Errors. 7th edition. Cedar Hill, TX: Texasoft Works SDA Software.
Morriss, F. H., Abramowitz, P. W., Nelson, S. P., Milavetz, G., Michael, S. L., Gordon, S. N., Pendergast, J. F., & Cook, E. F. (2009). Effectiveness of a Barcode Medication Administration System in Reducing Preventable Adverse Drug Events in a Neonatal Intensive Care Unit: A Prospective Cohort Study. The Journal of Pediatrics, 154(3), 363-368.e361. https://doi.org/10.1016/j.jpeds.2008.08.025
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical Error Reduction and Prevention. StatPearls Publishing, Treasure Island (FL). http://europepmc.org/abstract/MED/29763131 http://europepmc.org/books/NBK499956 https://www.ncbi.nlm.nih.gov/books/NBK499956
Ross, L. M., Wallace, J., & Paton, J. Y. (2000). Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Archives of Disease in Childhood, 83(6), 492-497. https://doi.org/10.1136/adc.83.6.492
Santesteban, E., Arenas, S., & Campino, A. (2015). Medication errors in neonatal care: a systematic review of types of errors and effectiveness of preventive strategies. Journal of Neonatal Nursing, 21(5), 200-208.
Tajik, M. I. (2020). Medication errors.
Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., Tutty, M. A., West, C. P., & Shanafelt, T. D. (2018). Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic Proceedings, 93(11), 1571-1580. https://doi.org/10.1016/j.mayocp.2018.05.014
Thomas, B., Paudyal, V., MacLure, K., Pallivalapila, A., McLay, J., El Kassem, W., Al Hail, M., & Stewart, D. (2019). Medication errors in hospitals in the Middle East: a systematic review of prevalence, nature, severity and contributory factors. European Journal of Clinical Pharmacology, 75(9), 1269-1282. https://doi.org/10.1007/s00228-019-02689-y
Valencia Quintero, A. F., Amariles, P., Rojas Henao, N., & Granados, J. (2021). [Medication errors in pediatrics]. Andes Pediatr, 92(2), 288-297. https://doi.org/10.32641/andespediatr.v92i2.1357 (Errores de medicación en pediatría.)
Vaziri, S., Fakouri, F., Mirzaei, M., Afsharian, M., Azizi, M., & Arab-Zozani, M. (2019). Prevalence of medical errors in Iran: a systematic review and meta-analysis. BMC Health Services Research, 19(1), 622. https://doi.org/10.1186/s12913-019-4464-8
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Murooj Shukry, Mohammed Hamed Alotaibi, Manal Bajammal, Nissreen Althaqafi, Saleh Alghamdi
This work is licensed under a Creative Commons Attribution 4.0 International License.
