MEDICATION ERRORS IN PEDIATRIC PRACTICE - INSIGHTS FROM A CONTINUOUS QUALITY IMPROVEMENT APPROACH

The objective was to assess the incidence and consequences of medicati on errors, highlight sources of recurrent error and institute changes in practice to prevent their recurrence. Utilising a continuous qualit y improvement approach, a 2-year prospective cohort study was undertak en using an adverse incident reporting scheme. A multidisciplinary com mittee analysed medication error reports, classifying them according t o type (prescription, supply or administration), severity (serious or not serious) and clinical outcome. Changes in policy and practice were implemented to reduce the frequency of errors. There were 441 reporte d medication errors in the study period, during which 682 patients wer e admitted for 5315 inpatient days. Errors were more seven times likel y to occur in the intensive care setting. Doctors accounted for 72% of errors and prescription errors doubled when new doctors joined the ro tation. Most errors (68%) were detected prior to drug administration. Twenty-four serious medication errors were not detected in advance, bu t only 4 had overt clinical consequences. Excluding prevented errors a nd appropriate deviations from prescribed therapy, there were 117 actu al medication errors (1/5.8 admissions, or 1/45 inpatient days). Durin g the 2nd year of the scheme, the incidence of all reported errors, ad ministration errors and serious errors fell, but the prescription erro r rate remained constant. Conclusions Medication errors occurred commo nly in this study, but adverse consequences were rare. The non-punitiv e, multidisciplinary approach to medication errors utilised in this st udy increased staff vigilance, highlighted sources of recurrent error, and led to changes in drug policies and staff training, which resulte d in improved patient safety and quality of care.