ERRORS IN PAEDIATRIC INPATIENTS
MA, Barber N, Franklin BD, Wong ICK
Department of Practice and Policy and Centre of Paediatric Pharmacy
Research, School of Pharmacy, University of London, 29-39 Brunswick
Square, London WC1N 1AX
Medication errors are not uncommon in paediatrics, particularly dosing errors1.
There is no drug chart/case note review study of paediatric prescribing errors
in the UK, all studies focused on analysis of incident reports.
To establish the feasibility of a multi-centre study investigating the
incidence and nature of paediatric prescribing errors.
A review of the drug charts was undertaken for 2 weeks by the senior
pharmacist for each of the paediatric intensive care unit (PICU), surgical, and
medical wards at a large paediatric hospital. The researcher accompanied the
senior pharmacists during their visits to these wards and recorded any
prescribing errors identified. The pharmacists were given a list of events that
might trigger an investigation into whether a prescribing error had occurred.
The pharmacists for all three wards reviewed a total of 1066 medication
orders. Various types of prescribing errors were identified. In the surgical,
medical and PICU wards, 58, 34 and 70 errors were identified respectively; 51%
of these errors involved the use of abbreviations. If these were excluded, the
most common types were illegibility and incomplete prescriptions. The latter
included not indicating the dose, route, frequency and duration of the drug, and
not signing the prescription. Dosing errors were the second most frequent type
and accounted for 5 (31%) and 2 (15%) of the errors in the surgical and medical
wards respectively, and 6 (12%) of the errors in the PICU. There was one tenfold
error in the PICU involving phenytoin, of which the first dose was given to the
patient but no harm resulted. The prescribing error rates in the surgical,
medical and PICU wards were 7.9, 8.0, and 7.6 per 100 medication orders
respectively. The dosing error rates were 2.5, 1.2 and 0.9 per 100 medication
orders in the surgical, medical and PICU wards respectively.
The results demonstrate that this data collection method is feasible, and
can be used in a multi-centre study of prescribing errors in paediatrics.
Various types of prescribing errors were identified, and their incidences were
greater than those reported in similar studies in the USA2-3, which
ranged from 0.47 – 2.7 per 100 medication orders. There is a need to reduce
medication errors in children, particularly dosing errors.
Wong IC, Ghaleb MA, Franklin BD, et al. Incidence and
nature of dosing errors in paediatric medications. Drug Saf 2004; 27(9):
Blum KV, Abel SR, Urbanski CJ, et al. Medication error
prevention by pharmacists. Am J Health Sys Pharm 1988; 45(9): 1902-1903.
Folli HL, Poole RL, Benitz WE, et al. Medication errors
prevention by clinical pharmacists in two children's hospitals. Pediatrics
1987; 79(5): 718-722
Presented at the HSRPP Conference 2005, Reading