Prevention of Medication Errors

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The incidence of medication errors

Of all medical errors, medication errors are one of the most common [1] as well as the most frequent cause of adverse events [2], [3]; they account for 19% to 20% of all adverse events. Of all hospitalized patients, 2.43% develop a clinically important adverse drug event (ADE) during their hospitalization [4]. A recent study concluded that medical errors are underreported significantly in incident reporting systems that are used by many hospitals. Especially if errors did not reach the patient,

Medication errors in pediatrics

Children are at increased risk for ADEs. Pharmacologic factors, including age-based variability in absorption, metabolism, and excretion of drugs as compared with adults, pose special vulnerabilities to the adverse effects of overdosing (often by an order of magnitude). Physiologic factors, such as the universal need for weight and body surface area considerations in dosing, also make the medication process in pediatric patients more prone to errors.

Weight-based dosing is prone to errors as

The cost of medication errors

Medication errors do not cost lives only. ADEs also were shown to have a significant effect on morbidity, length of stay, and cost in hospitalized patients [4]. Of all hospitalized patients, it is estimated that between 0.7% and 6.5% develop a clinically important ADE [22]. In paired regression analyses of 4108 admissions, the additional length of stay that was associated with an ADE was 2.2 days; the increase in cost that was associated with an ADE was $3244. For preventable ADEs, the length

Medication errors as system failures

Medical errors have many causes; a major central theme is the increasing complexity of patient care. First, the infrastructure of care systems consists of many entities, agents, and components, and optimal management of personnel, resources, and time often may be at odds with a proactive approach to prevention and management of medical errors. Second, the interfaces and methods by which patients and providers interact with the care system may be confusing, with ambiguous messages leading to

Detecting medication errors

To create successful interventions that reduce and prevent medication errors, there must be a framework in place by which latent and active system failures can be anticipated and discovered.

Design intelligently

Organizations with high requirements for process reliability in performance and accountability (eg, the airline industry) long have recognized that humans and machines have different strengths and vulnerabilities. Humans, unlike machines, introduce more variability and can err in unexpected ways; however, humans also are resourceful, flexible, and inventive and are much more likely to recover from a serious error. Machines can perform tasks repetitively without fatigue and with a measurably

Summary

We have outlined tools and techniques to reduce medication errors in pediatric patients. Many of these tools are barely beyond the proof-of concept stage and are not adapted universally. Barriers to implementation include complexity and cost in form of time and resources. Table 1 shows the interventions, their cost, and their likelihood of success.

For a lasting effort of error reduction and prevention, the most important component is the will of organizational leadership to make change happen.

Find and fix the “broken” process

In a neonatal ICU at an academic center, the medication process for total parenteral nutrition (TPN) was found to be an error prone process. Initial assessment included an analysis of the process from prescribing, ordering, processing, administration, and documentation with estimates of the likelihood of failure at each step from audited measures. The failure modes analysis identified the traditional paper based, computationally intensive ordering process, done by first year residents, to be

Acknowledgments

The authors would like to thank Dr. Marvin Cornblath for critical review of this manuscript. This work was supported by the Center for Innovation and Quality Patient Care at the Johns Hopkins Hospital.

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