Abstract
The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010–2014. We included reports from public hospitals on patients aged 0–17 years and categorized by reporters as medication-related. Reports from psychiatric wards and outpatient clinics were excluded. A ME was defined as any medication-related error occurring in the medication process whether harmful or not. MEs were categorized as harmful if they resulted in actual harm or interventions to prevent harm. MEs were further categorized according to occurrence in the medication process, type of error, and the medicines involved. A total of 2071 MEs including 487 harmful MEs were identified. Most MEs occurred during prescribing (40.8%), followed by dispensing (38.7%). Harmful MEs occurred mainly during dispensing (40.3%). Dosing errors were the most reported type of error, 47.7% of all MEs and 45.4% of harmful MEs. Antibiotics and analgesics were the most frequently reported medication classes. Common medicines associated with MEs included morphine, paracetamol, and gentamicin. MEs caused no harm (74.9%), mild (11.7%), moderate (10.5%), or severe harm (1.3%), but none were lethal.
Conclusion: MEs in hospitalized children occur in all medication processes and mainly involve dosing errors. Strategies should be developed to prevent MEs as these still threaten medication safety in pediatric inpatients.
What is known: • Hospitalized children are more likely to experience medication errors than adults. • Voluntary national and local reporting and learning systems have previously been used to describe the nature and types of medication errors. |
What is new: • Medication errors in hospitalized children occur in all steps of the medication process, most frequently involving dosing errors and most commonly involving morphine, paracetamol, and gentamicin. • Of the medication errors, 1.3% cause severe harm, but no fatal errors were reported. |
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Abbreviations
- ATC:
-
Anatomical Therapeutic Chemical Classification System
- DPSA:
-
Danish Patient Safety Authority
- DPSD:
-
Danish Patient Safety Database
- ME:
-
medication errors
- NCC MERP:
-
The National Coordinating Council for Medication Error Reporting and Prevention
- WHO:
-
World Health Organization
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Acknowledgements
We wish to thank the Division for Learning at the Danish Patient Safety Authority for their contribution to this study. Thank you for your help and support making the data from the Danish Patient Safety Database available to us.
Funding
This study was funded by Amgros I/S, The Hospital Pharmacies and Amgros’ Research and Development Fund, Copenhagen, Denmark, and the Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark. The organizations sponsored the PhD scholarship of Rikke Rishoej. Lene Juel Kjeldsen is employed by Amgros I/S.
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RMR conceptualized and designed the study and drafted the initial manuscript and was responsible for data collection and initial analysis.LJK, HBTC, ABA, and JH contributed to the conceptualization of the study, data analysis, and interpretation of data and critically reviewed the manuscript. All authors approved the final manuscript as submitted.
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Rikke Rishoej received grants from Pfizer to attend the 23rd Congress of European Association of Hospital Pharmacists in Vienna in 2016. Anna Birna Almarsdóttir declares that she has no conflict of interest. Henrik Boye Thybo Christesen declares that he has no conflict of interest. Jesper Hallas declares that he has no conflict of interest. Lene Juel Kjeldsen declares that she has no conflict of interest.
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This article does not contain any studies with human participants or animals performed by any of the authors.
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Communicated by Nicole Ritz
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Rishoej, R.M., Almarsdóttir, A.B., Christesen, H.T. et al. Medication errors in pediatric inpatients: a study based on a national mandatory reporting system. Eur J Pediatr 176, 1697–1705 (2017). https://doi.org/10.1007/s00431-017-3023-8
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DOI: https://doi.org/10.1007/s00431-017-3023-8