Skip to main content
NCBI home page
Archives of Disease in Childhood logoLink to Archives of Disease in Childhood
. 2000 Dec;83(6):492–497. doi: 10.1136/adc.83.6.492

Medication errors in a paediatric teaching hospital in the UK: five years operational experience

L Ross 1, J Wallace 1, J Paton 1, T STEPHENSON 1
PMCID: PMC1718567  PMID: 11087283

Abstract

BACKGROUND—In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients.
AIMS—To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence.
METHODS—Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions.
RESULTS—Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year.
CONCLUSION—The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further.


Full Text

The Full Text of this article is available as a PDF (132.4 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Bates D. W., Cullen D. J., Laird N., Petersen L. A., Small S. D., Servi D., Laffel G., Sweitzer B. J., Shea B. F., Hallisey R. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):29–34. [PubMed] [Google Scholar]
  2. Bates D. W., Leape L. L., Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med. 1993 Jun;8(6):289–294. doi: 10.1007/BF02600138. [DOI] [PubMed] [Google Scholar]
  3. Bordun L. A., Butt W. Drug errors in intensive care. J Paediatr Child Health. 1992 Aug;28(4):309–311. doi: 10.1111/j.1440-1754.1992.tb02674.x. [DOI] [PubMed] [Google Scholar]
  4. Brennan T. A., Leape L. L. Adverse events, negligence in hospitalized patients: results from the Harvard Medical Practice Study. Perspect Healthc Risk Manage. 1991 Spring;11(2):2–8. doi: 10.1002/jhrm.5600110202. [DOI] [PubMed] [Google Scholar]
  5. Brennan T. A., Leape L. L., Laird N. M., Hebert L., Localio A. R., Lawthers A. G., Newhouse J. P., Weiler P. C., Hiatt H. H. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370–376. doi: 10.1056/NEJM199102073240604. [DOI] [PubMed] [Google Scholar]
  6. Charatan F. Family compensated for death after illegible prescription. BMJ. 1999 Dec 4;319(7223):1456–1456. doi: 10.1136/bmj.319.7223.1456. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Cullen D. J., Bates D. W., Small S. D., Cooper J. B., Nemeskal A. R., Leape L. L. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995 Oct;21(10):541–548. doi: 10.1016/s1070-3241(16)30180-8. [DOI] [PubMed] [Google Scholar]
  8. Ferner R. E., Whittington R. M. Coroner's cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986-1991. J R Soc Med. 1994 Mar;87(3):145–148. doi: 10.1177/014107689408700311. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Folli H. L., Poole R. L., Benitz W. E., Russo J. C. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics. 1987 May;79(5):718–722. [PubMed] [Google Scholar]
  10. Koren G., Haslam R. H. Pediatric medication errors: predicting and preventing tenfold disasters. J Clin Pharmacol. 1994 Nov;34(11):1043–1045. doi: 10.1002/j.1552-4604.1994.tb01978.x. [DOI] [PubMed] [Google Scholar]
  11. Leape L. L., Bates D. W., Cullen D. J., Cooper J., Demonaco H. J., Gallivan T., Hallisey R., Ives J., Laird N., Laffel G. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):35–43. [PubMed] [Google Scholar]
  12. Leape L. L., Brennan T. A., Laird N., Lawthers A. G., Localio A. R., Barnes B. A., Hebert L., Newhouse J. P., Weiler P. C., Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991 Feb 7;324(6):377–384. doi: 10.1056/NEJM199102073240605. [DOI] [PubMed] [Google Scholar]
  13. Lesar T. S., Lomaestro B. M., Pohl H. Medication-prescribing errors in a teaching hospital. A 9-year experience. Arch Intern Med. 1997 Jul 28;157(14):1569–1576. [PubMed] [Google Scholar]
  14. Lyons R., Payne C., McCabe M., Fielder C. Legibility of doctors' handwriting: quantitative comparative study. BMJ. 1998 Sep 26;317(7162):863–864. doi: 10.1136/bmj.317.7162.863. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Paton J., Wallace J. Medication errors. Lancet. 1997 Mar 29;349(9056):959–960. doi: 10.1016/s0140-6736(05)62746-8. [DOI] [PubMed] [Google Scholar]
  16. Raju T. N., Kecskes S., Thornton J. P., Perry M., Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989 Aug 12;2(8659):374–376. doi: 10.1016/s0140-6736(89)90548-5. [DOI] [PubMed] [Google Scholar]
  17. Selbst S. M., Fein J. A., Osterhoudt K., Ho W. Medication errors in a pediatric emergency department. Pediatr Emerg Care. 1999 Feb;15(1):1–4. doi: 10.1097/00006565-199902000-00001. [DOI] [PubMed] [Google Scholar]
  18. Vincer M. J., Murray J. M., Yuill A., Allen A. C., Evans J. R., Stinson D. A. Drug errors and incidents in a neonatal intensive care unit. A quality assurance activity. Am J Dis Child. 1989 Jun;143(6):737–740. doi: 10.1001/archpedi.1989.02150180119032. [DOI] [PubMed] [Google Scholar]

Articles from Archives of Disease in Childhood are provided here courtesy of BMJ Publishing Group

RESOURCES