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Abstract
Introduction Tenfold dose errors are feared in paediatric practice. Conventionally hospitals run voluntary reporting systems to capture errors with intention to spot patterns and learn lessons. We describe dosing errors in a tertiary children’s hospital and the published literature on 10x dose errors.
Method Review of medication error reports and investigations in 300 bedded tertiary UK children’s hospital with 10 in-patient wards between 2010 and 2015. Data was collected by a voluntary reporting computerised system (Datix Ltd.)
Results Over 5 years, 890 medication incidents were voluntarily reported in 177201 (1 per 199) patient bed days. 353 (39%) involved drug dosing errors, mainly at prescribing (42%) or administration stages (35%). The drug partially or fully reached the patient in 290.
Magnitude of dosing error was discernible in 250/353 (71%) of cases (Table 1) with 158 (63%) errors over twice intended dose (1 per 1100 patient bed days). Tenfold or greater errors were reported in 36/250 (14%) (1 per 4922 patient bed days) with the following characteristics: 28/36 (77%) reached the patient, 8/36 (22%) resulted in harm, highest incidence occurred in critical care (Table 2) and the commonest medication types involved opiates, antimicrobials and anaesthetic drugs (Table 3).
Magnitude of reported dose errors compared to intended dose. Sufficient information was discernible for 252 cases
Number of =10x dose errors between 2010 and 2015
Medication types where =10× dose errors occurred
Discussion The literature on 10x dose errors is sparse with one comparable study from a Canadian children’s hospital showing similar rates.
Quality improvements projects are most effective when tailored to microsystems where outcomes are measurable such as an individual wards. Tenfold medication errors in children in this study are share similar incidence as that defined for rare diseases. Its rarity suggests strategies for reduction may be most productive if designed across a whole national healthcare system rather than by a ward or hospital basis. Further work is being undertaken across our region with data from various healthcare settings with ambition for national surveillance.