Medication Errors

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Medication Errors

• Paediatric Department
• Bradford Teaching Hospitals

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Medication Errors in Paediatrics

• Background
• Practical examples (workshops)
• Case studies
• Key messages

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Background

• Medication errors (prescribing, dispensing and
  administering) are very common in Paediatrics and
  Neonates
• Medication errors are the commonest adverse
  incidents reported in our Department ( 100
  reported between April and October 2005)

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Medication Errors

• Prescription
• Wrong dose
• Illegible
• Signature not identified
• Wrong drug
• Wrong concentration
• Administration
• Wrong patient
• Wrong drug
• Wrong dose
• Wrong infusion/ rate

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Medication Errors During Hospital Admission

• Can occur at any of the following stages
• Prescribing by GP or other health professional in
  the community
• Dispensing from local chemist
• Administration by parents/ patients
• Prescribing in hospital by doctor
• Dispensing from Hospital Pharmacy
• Administration by Nursing staff

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Possible Explanations

• Lack of experience (children are not small
  adults!!)
• Lack of training/ induction
• Lack of robust systems to prevent errors
• Writing unclear/ incomplete illegible
• No double checking
• Working pressures/ lack of supervision
• Medical records/ clinic letter not available

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Possible Explanations (cont)

• Some drugs have different interactions and side
  effects in children.
• Drug allergies are not that uncommon in children
  (possibly on the increase).
• Drug doses in children should be calculated based
  on weight and sometimes on body surface area.

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Key Messages/ Lessons Learnt

• Robust induction of new staff
• Competence-based training
• Systems to report errors and learn lessons
• Systems to prevent errors
• Dissemination of lessons learnt
• Continuous developing of systems to prevent errors

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Systems to Report Errors

• Incident reporting
• Regular prescription audits
• Regular Risk Management Meetings to discuss errors

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Systems to Prevent Errors

• Regular ward rounds by Paediatric Pharmacists
• 10 Steps to Safe Prescribing in Paediatrics
• 10 Steps to Safe Prescribing for Neonates
• Copies of BNF for Children in all clinical areas
• Lists of commonly used drugs in Paediatrics on
  ward trolleys in the Childrens wards (surgical
  medical) and on the Intranet

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Dissemination of Lessons Learnt

• Multidisciplinary Clinical Governance Meetings
• Monthly Clinical Governance Newsletter

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Clinical Governance Newsletter
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New Systems

• Involve parents of children with chronic diseases
  in safe prescribing
• Specialist Nurse-led prescribing (Asthma ,
  Diabetes, Palliative Care)
• Develop 10 Steps to Safe Drug Administration
• Future electronic prescribing
• Community- PACE Event on Patient Safety