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

Intercepting Medication Errors in Pediatric In-patients Using a Prescription Pre-audit Intelligent Decision System: A Single-center Study

OBJECTIVES

Medication errors can happen at any phase of the medication process at health care settings. The objective of this study is to identify the characteristics of severe prescribing errors at a pediatric hospital in the inpatient setting and to provide recommendations to improve medication safety and rational drug use.

METHODS

This descriptive retrospective study was conducted at a tertiary pediatric hospital using data collected from Jan. 1st, 2019 to Dec. 31st, 2020. During this period, the Prescription Pre-audit Intelligent Decision System was implemented. Medication orders with potential severe errors would trigger a Level 7 alert and would be intercepted before it reached the pharmacy. Trained pharmacists maintained the system and facilitated decision making when necessary. For each order intercepted by the system the following patient details were recorded and analyzed: patient age, patient's department, drug classification, dosage forms, route of administration, and the type of error.

RESULTS

A total of 2176 Level 7 medication orders were intercepted. The most common errors were associated with drug dosage, administration route, and dose frequency, accounting for 35.2%, 32.8% and 13.2%, respectively. Of all the intercepted oerrors. 53.6% occurred in infants aged < 1 year. Administration routes involved were mainly intravenous, oral and external use drugs. Most alerts came from the neonatology department and constituted 40.5% of the total alerts, followed by the nephrology department 15.9% and pediatric intensive care unit (PICU) 11.3%. As to dosage forms, injections accounted for 50.4% of alerts, with 21.3% attributable to topical solutions, 9.1% to tablets, and 5.7% to inhalation. Anti-infective agents were the most common therapeutic drugs prescribed with errors.

CONCLUSIONS

The Prescription Pre-audit Intelligent Decision System, with the supervision of trained pharmacists can validate prescriptions, increase prescription accuracy, and improve drug safety for hospitalized children. It is a medical service model worthy of consideration.

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement

BACKGROUND

To protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data could provide this but are often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates.

OBJECTIVE

Our aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients.

METHODS

We conducted a retrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. The following characteristics were included: error severity, patient age, drug involved, error type, and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analyzed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups.

RESULTS

Neonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%).

CONCLUSIONS

Incident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviors, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community in their future implementation. The utility of incident reports to direct improvement efforts may offset the limitations in their representativeness.

What causes prescribing errors in children? Scoping review

OBJECTIVES

(1) Systematically assemble, analyse and synthesise published evidence on causes of prescribing error in children. (2) Present results to a multidisciplinary group of paediatric prescribing stakeholders to validate findings and establish how causative factors lead to errors in practice.

DESIGN

Scoping review using Arksey and O'Malley's framework, including stakeholder consultation; qualitative evidence synthesis.

METHODS

We followed the six scoping review stages. (1) Research question-the research question was 'What is known about causes of prescribing error in children?' (2) Search strategy-we searched MEDLINE, EMBASE, CINAHL (from inception to February 2018), grey literature and reference lists of included studies. (3) Article selection-all published evidence contributing information on the causes of prescribing error in children was eligible for inclusion. We included review articles as secondary evidence to broaden understanding. (4) Charting data-results were collated in a custom data charting form. (5) Reporting results-we summarised article characteristics, extracted causal evidence and thematically synthesised findings. (6) Stakeholder consultation-results were presented to a multidisciplinary focus group of six prescribing stakeholders to establish validity, relevance and mechanisms by which causes lead to errors in practice.

RESULTS

68 articles were included. We identified six main causes of prescribing errors: children's fundamental differences led to individualised dosing and calculations; off-licence prescribing; medication formulations; communication with children; and experience working with children. Primary evidence clarifying causes was lacking.

CONCLUSIONS

Specific factors complicate prescribing for children and increase risk of errors. Primary research is needed to confirm and elaborate these causes of error. In the meantime, this review uses existing evidence to make provisional paediatric-specific recommendations for policy, practice and education.

Exploring the human factors of prescribing errors in paediatric intensive care units

OBJECTIVE

To explore the factors contributing to prescribing error in paediatric intensive care units (PICUs) using a human factors approach based on Reason's theory of error causation to support planning of interventions to mitigate slips and lapses, rules-based mistakes and knowledge-based mistakes.

METHODS

A hierarchical task analysis (HTA) of prescribing was conducted using documentary analysis. Eleven semistructured interviews with prescribers were conducted using vignettes and were analysed using template analysis. Contributory factors were identified through the interviews and were related to tasks in the HTA by an expert panel involving a PICU clinician, nurse and pharmacist.

RESULTS

Prescribing in PICU is composed of 30 subtasks. Our findings indicate that cognitive burden was the main contributory factor of prescribing error. This manifested in two ways: physical, associated with fatigue, distraction and interruption, and poor information transfer; and psychological, related to inexperience, changing workload and insufficient decision support information. Physical burden was associated with errors of omission or selection; psychological burden was linked to errors related to a lack of knowledge and/or awareness. Social control through nursing staff was the only identified control step. This control was dysfunctional at times as nurses were part of an informal mechanism to support decision making, was ineffective.

CONCLUSIONS

Cognitive burden on prescribers is the principal latent factor contributing to prescribing error. This research suggests that interventions relating to skill mix, and communication and presentation of information may be effective at mitigating rule and knowledge-based mistakes. Mitigating fatigue and standardising procedures may minimise slips and lapses.