Drug error rate low for children but half of parents not told when mistake occurs

November 19, 2000

Medication errors in a paediatric teaching hospital in the UK: five years' operational experience

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Half of parents were not told when a drug error had occurred in the treatment of their child, shows a new study in the Archives of Disease in Childhood. The study involved a review of drug treatment errors in a children's teaching hospital over five years from 1994 to 1999.

The overall error rate was low, with one mistake for every 662 admissions to the hospital. But four out of 10 mistakes occurred in children under the age of 2; one fifth occurred in infants up to the age of four weeks. Almost two thirds of mistakes happened on medical wards. Pharmacy staff made one in five of the mistakes and just under 60 per cent of the mistakes were made by nurses, who administer most of the drugs in hospitals. Although this figure seems high, the authors emphasise that nurses are part of the solution, rather than a major problem. "There has been a deliberate shift towards nurses giving most medication because their systems for error trapping are much better than when doctors often gave important medications alone, without checking," they stress.

Most of the errors were classified as "minor" yet almost one in ten required some intervention, which, suggest the authors, may be a result of trying to downplay the incident for fear of repercussion. Analysis of the reporting forms showed that 48 per cent of parents had not been told of the mistake, which the authors considered to be high.

The greatest number of mistakes involved antibiotics, parenteral nutrition and intravenous fluids, and anticancer drugs. And over half of all the mistakes involved drugs given intravenously. Fifteen of the incidents - 8 per cent - involved drugs given in doses 10 times too high or too low.

Training was increased, double checking of drug dispensing by the pharmacy introduced, and the error report form was changed to make it less punitive, during the period under study. All of these reduced the annual error rate.

"The medical profession in the UK has come rather late to admitting openly that adverse medical incidents including medication errors are an important problem," say the authors. Despite the fact that the error rate is low, there is no room for complacency, they conclude, and there are plenty of ways in which the rate could be reduced further still.

James Paton, Senior Lecturer in Paediatric Respiratory Diseases, Royal Hospital for Sick Children, Glasgow, UK
Email: J.Y.Paton@clinmed.gla.ac.uk

BMJ Specialty Journals

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