Medication errors in a pediatric emergency department

Objective: To initiate investigation into the medication errors that occur in a pediatric emergency department. These errors have the potential for si gnificant morbidity and mortality, as well as costly litigation. Methods: We conducted a retrospective chart review of all medication and in travenous fluid errors identified in a pediatric emergency department throu gh incident reports filed over a 5-year period. An attempt was made to dete rmine who was involved with the errors and what caused the errors. The pati ent outcomes were noted and classified according to clinical significance u sing previously published criteria. Results: Thirty-three incident reports involving medication or intravenous fluid errors were analyzed, Most errors occurred on the evening and night s hifts, Nurses were involved in 39% of reported errors; the nurse and emerge ncy physician were jointly involved in 36%, The most common error was an in correct dose of medication (35%) or incorrect medication given (30%). In on e third of the cases, the family was not made aware of the error. In 12%, p atients required additional treatment, and one was admitted to the hospital because of the error. There were no deaths. Conclusion: Incorrect recording of patient weights leading to an incorrect medication dose and failure to note drug allergy are common causes for medi cation errors in the pediatric emergency department. Incorrect drugs and IV fluids are given because of similar names and packaging. Many of the error s in the ED seem to be preventable.