Article Text
Abstract
Background 2017 a rise in serious drug related medical errors in pediatric care at Sahlgrenska University hospital was discovered. 2018 a pediatric Clinical Decision Support System (CDSS) called ePed with weight based dose calculation, dosage control and easy access to pediatric drug information was integrated with the Electronic Medical Record.
Aim Analyze causes and underlying factors to serious drug related medical errors, labeled Lex Maria, in children and further evaluate if these errors could be prevented within the framework of ePed.
Method 28 Lex Maria cases in children ≤16 years were registered during 2015–2017 at Sahlgrenska University hospital, Gothenburg. These were analyzed and summarized according to type of error, underlying cause and when during the drug managing process the error occurred. Finally, comparison between years was made.
Results 2015 and 2016 five Lex Maria cases occurred respectively. 2017 the number increased to 18 cases. Most commonly the patients received an incorrect dose. Errors divide equally between prescription, preparation and administration. Drugs requiring dilution were of certain risk especially when diluted in several steps. Midazolam was the most frequently involved drug. In 2017 especially one ward stands out in numbers and was responsible for 10 of the 18 cases.
Conclusions ePed will help to avoid human calculation errors in prescription and provides easy access to pediatric drug information facilitating drug preparation and administration. Nurses are particularly exposed to medication incidents since they usually are the last link to the patient and need to be their own control. High-risk medicines need to be identified and made safe. A complex interplay between individual/human and systemic factors contribute to errors. However, to reduce serious drug related errors a CDSS is of great value but adequate education for medical staff, both pharmacologically and about the system is vital. Future follow up will be needed.
Disclosure(s) Nothing to disclose