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Results of a program to prevent medication errors in a pediatric emergency department

Vilà De Muga M, Messegué Medà M, Astete J, Luaces Cubells C

Servicio de Urgencias de PediatrĂ­a, Servicio de PediatrĂ­a, Hospital Sant Joan de DĂ©u, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, Spain.

Background and objective: Drug prescription errors are a significant cause of
preventable morbidity and mortality in children. Our aim was to assess whether the
frequency of medication error decreased after a prevention program was implemented
in a pediatric emergency department.
Material and methods: Observational pre- and postintervention study. We identified
errors made in November 2009 (preintervention period) by reviewing patient records.
Errors were classified by type (dose, indication, route of administration), level of
seriousness (low, moderate, high), and associated factors (staff experience, seriousness of
the emergency, day of the week, hour of the day). In 2010 sessions to provide
information about the detected errors were held and informative posters were hung in
the department. Errors were again identified in November 2010 (postintervention
period) and the results were compared.
Results: Errors were made most often with bronchodilators, corticosteroids, and antiinflammatory
drugs. In the first period, out of 445 prescriptions made, 49 errors (11%)
were detected; in the second period, 48 errors in 557 prescriptions (8.6%) were
detected. The difference was not significant. The rate of dosage error decreased
significantly between the 2 periods (7.4% vs 3.8%, P=.016), but we saw no significant
changes in incorrect indication, choice of route of administration, or seriousness. During
the postintervention period, fewer errors were made in the most serious emergencies
(11.6% vs 5.7%; P=.005) and between midnight and 8 a.m. (16.2% vs 6.1%; P=.02).
Conclusions: The error prevention program allowed us to reduce some types of
medication error but follow-up and continued insistence on vigilance is required.

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