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Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors

Huynh, C; Wong, IC; Correa-West, J; Terry, D; McCarthy, S; (2017) Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors. Paediatric Drugs , 19 (2) pp. 99-105. 10.1007/s40272-017-0214-8. Green open access

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Abstract

Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.

Type: Article
Title: Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors
Location: Switzerland
Open access status: An open access version is available from UCL Discovery
DOI: 10.1007/s40272-017-0214-8
Publisher version: http://dx.doi.org/10.1007/s40272-017-0214-8
Language: English
Additional information: © Springer International Publishing Switzerland 2017. The final publication is available at Springer via http://dx.doi.org/10.1007/s40272-017-0214-8.
UCL classification: UCL
UCL > Provost and Vice Provost Offices
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy > Practice and Policy
URI: https://discovery.ucl.ac.uk/id/eprint/1542455
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