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216 Medication Errors in Paediatrics: PAtient, Pill and Process
  1. J Maaskant1,
  2. E Zwart2,
  3. D Bosman1,
  4. R Flint3,
  5. H Vermeulen2
  1. 1Women’s and Children’s Clinic
  2. 2Quality Assurance and Process Innovation
  3. 3Pharmacy, Academic Medical Center, Amsterdam, The Netherlands

Abstract

Background and aims Medication errors, defined as preventable events that may lead to incorrect medication use or patient harm, is a big problem in healthcare. Especially children are considered to be at high risk of experiencing harm due to medication errors. Interventions to prevent errors have led to limited improvements. If, however, we could identify error prone situations, more effective interventions could be developed and thereby prevent patient harm. The purpose of this study was to establish the prevalence of harm due to medication errors categorized in characteristics of Patients and Pills in all phases of the medication Process.

Methods We investigated medication errors using a multifaceted approach including direct observations, and review of patients’ files, pharmacy logs and voluntary incidents reports. All medication errors were classified in terms of (potential) patient harm.

Results We collected data of 426 patients admitted to five paediatric, non-ICU wards during three months. In 236 patients at least one medication error was identified: 55% (236/426). A total of 39 errors were harmful affecting 37 patients: 9% (37/426).

Significantly more harmful medication errors were found in patients after surgery: 68% (25/37).

In 59% (23/39)of the ADEs analgesics were involved: non-opioids 49% (19/39) and opioids 10% (4/39). Prescribing and administrating were the most error prone activities: 28% (11/39)and 62% (24/39).

Conclusions Our results identified error prone Patients, Pills and medication Process. This will guide future targeted interventions to improve medication safety for children.

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