Identifying and assessing potential harm of medication errors and potentially unsafe medication practices in paediatric hospital settings: a field study

Rikke Mie Rishoej*, Anna Birna Almarsdóttir, Henrik Thybo Christesen, Jesper Hallas, Lene Juel Kjeldsen

*Kontaktforfatter for dette arbejde

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Resumé

Background: Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. Methods: A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss’ Kappa. Results: A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8%. No actual harm to patients was observed during the study. Raters assessed the potential harm of 318 unique MEs and PUMPs. Only slight agreement was found (Kappa = 0.26–0.33). A 4-hour delay in the administration of intravenous cefuroxime received the highest harm score. Observations involving no information during prescribing and variations in medication preparation were considered potentially fatal for medications such as digoxin, morphine, enoxaparin and insulin. Conclusions: MEs and potentially unsafe practices and conditions may affect medication safety of hospitalized children. However, observed MEs did not result in any harm. The agreement among raters assessing the potential harm of observations was low. Alternative methods to determine the clinical relevance of errors are needed.

OriginalsprogEngelsk
TidsskriftTherapeutic Advances in Drug Safety
Vol/bind9
Udgave nummer9
Sider (fra-til)509-522
ISSN2042-0986
DOI
StatusUdgivet - 1. sep. 2018

Fingeraftryk

Pediatric Hospitals
Hospitalized Child
Patient Harm
Enoxaparin
Cefuroxime
Pharmacists
Morphine
Nurses
Observation
Insulin
Physicians
Safety

Citer dette

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abstract = "Background: Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. Methods: A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss’ Kappa. Results: A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8{\%}. No actual harm to patients was observed during the study. Raters assessed the potential harm of 318 unique MEs and PUMPs. Only slight agreement was found (Kappa = 0.26–0.33). A 4-hour delay in the administration of intravenous cefuroxime received the highest harm score. Observations involving no information during prescribing and variations in medication preparation were considered potentially fatal for medications such as digoxin, morphine, enoxaparin and insulin. Conclusions: MEs and potentially unsafe practices and conditions may affect medication safety of hospitalized children. However, observed MEs did not result in any harm. The agreement among raters assessing the potential harm of observations was low. Alternative methods to determine the clinical relevance of errors are needed.",
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Identifying and assessing potential harm of medication errors and potentially unsafe medication practices in paediatric hospital settings : a field study. / Rishoej, Rikke Mie; Almarsdóttir, Anna Birna; Thybo Christesen, Henrik; Hallas, Jesper; Juel Kjeldsen, Lene.

I: Therapeutic Advances in Drug Safety, Bind 9, Nr. 9, 01.09.2018, s. 509-522.

Publikation: Bidrag til tidsskriftTidsskriftartikelForskningpeer review

TY - JOUR

T1 - Identifying and assessing potential harm of medication errors and potentially unsafe medication practices in paediatric hospital settings

T2 - a field study

AU - Rishoej, Rikke Mie

AU - Almarsdóttir, Anna Birna

AU - Thybo Christesen, Henrik

AU - Hallas, Jesper

AU - Juel Kjeldsen, Lene

PY - 2018/9/1

Y1 - 2018/9/1

N2 - Background: Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. Methods: A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss’ Kappa. Results: A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8%. No actual harm to patients was observed during the study. Raters assessed the potential harm of 318 unique MEs and PUMPs. Only slight agreement was found (Kappa = 0.26–0.33). A 4-hour delay in the administration of intravenous cefuroxime received the highest harm score. Observations involving no information during prescribing and variations in medication preparation were considered potentially fatal for medications such as digoxin, morphine, enoxaparin and insulin. Conclusions: MEs and potentially unsafe practices and conditions may affect medication safety of hospitalized children. However, observed MEs did not result in any harm. The agreement among raters assessing the potential harm of observations was low. Alternative methods to determine the clinical relevance of errors are needed.

AB - Background: Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. Methods: A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss’ Kappa. Results: A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8%. No actual harm to patients was observed during the study. Raters assessed the potential harm of 318 unique MEs and PUMPs. Only slight agreement was found (Kappa = 0.26–0.33). A 4-hour delay in the administration of intravenous cefuroxime received the highest harm score. Observations involving no information during prescribing and variations in medication preparation were considered potentially fatal for medications such as digoxin, morphine, enoxaparin and insulin. Conclusions: MEs and potentially unsafe practices and conditions may affect medication safety of hospitalized children. However, observed MEs did not result in any harm. The agreement among raters assessing the potential harm of observations was low. Alternative methods to determine the clinical relevance of errors are needed.

KW - direct observations

KW - hospitalized children

KW - medication error

U2 - 10.1177/2042098618781521

DO - 10.1177/2042098618781521

M3 - Journal article

C2 - 30181859

AN - SCOPUS:85048772615

VL - 9

SP - 509

EP - 522

JO - Therapeutic Advances in Drug Safety

JF - Therapeutic Advances in Drug Safety

SN - 2042-0986

IS - 9

ER -