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PO-0331 The Effects Of Increased Awareness On Medication Error Disclosures
  1. L Fernandez-Restrepo,
  2. J Ruiz,
  3. MS Son,
  4. R Taylor
  1. Pediatric Critical Care, The University of Texas Health Science at San Antonio, San Antonio, USA

Abstract

Background Communicating medication errors is a crucial part of patient care. Children are exposed up to three times the rate of potentially dangerous adverse drug events. A previous evaluation of disclosure of medication errors identified barriers in communicating these errors.

Methods Two presentations on medication errors and how to improve their communication with patient/family were presented to the PICU team. A Medication Error Data Entry Form was used to collect the number and type of medication errors (only type C through I require immediate notification to the MD). Communication to family was documented in a separate form.

Results Thirty-four medication errors were recorded over a 4-month period (2 months before and 2 months after education). Fifty-three percent were type A errors (circumstances or events that have the capacity to cause error) while the remaining were type C (an error occurred that reached the patient but did not cause patient harm) (Table 1).

While the fellows did not participate in the communication of errors to patient/family before education, they did in 60% of the notifications afterwards. The two barriers to communication were “family was not available” (43%) and "error did not cause side effects" (57%).

Conclusion This study demonstrates that despite the effort to increase awareness of medication errors disclosure there was not an improvement in communicating of medication errors to the patient/family. A more systematic and aggressive approach to education on communication may be required to properly address and improve the disclosure of medication errors.

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