Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis
Introduction Medication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.Objectives To describe the incidence, nature and severity of medication errors in si...
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BMJ Publishing Group
2019-11-01
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| Series: | BMJ Open |
| Online Access: | https://bmjopen.bmj.com/content/9/11/e032686.full |
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| author | Ruchi Sinha Bryony Franklin Phillip Pratt |
| author_facet | Ruchi Sinha Bryony Franklin Phillip Pratt |
| author_sort | Ruchi Sinha |
| collection | DOAJ |
| description | Introduction Medication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.Objectives To describe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contribution of discrepancies in individual process steps to the occurrence of these errors.Methods We conducted a prospective observational study of simulated resuscitations subjected to video microanalysis, identification of medication errors, severity assessment and human reliability analysis in a large English teaching hospital. Fifteen resuscitation teams of two doctors and two nurses each conducted one of two simulated paediatric resuscitation scenarios.Results At least one medication error was observed in every simulated case, and a large magnitude (>25% discrepant) or clinically significant error in 11 of 15 cases. Medication errors were observed in 29% of 180 simulated medication administrations, 40% of which considered to be moderate or severe. These errors were the result of 884 observed discrepancies at a number of steps in the drug ordering, preparation and administration stages of medication use, 8% of which made a major contribution to a resultant medication error. Most errors were introduced by discrepancies during drug preparation and administration.Conclusions Medication errors were common with a considerable proportion likely to result in patient harm. There is an urgent need to optimise existing systems and to commission research into new approaches to increase the reliability of human interactions during administration of medication in the paediatric emergency setting. |
| format | Article |
| id | doaj-art-3dae96aebf02488dad1f9b63cf1b6b80 |
| institution | OA Journals |
| issn | 2044-6055 |
| language | English |
| publishDate | 2019-11-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | BMJ Open |
| spelling | doaj-art-3dae96aebf02488dad1f9b63cf1b6b802025-08-20T01:54:30ZengBMJ Publishing GroupBMJ Open2044-60552019-11-0191110.1136/bmjopen-2019-032686Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysisRuchi Sinha0Bryony Franklin1Phillip Pratt2Department of Pathology & Lab Medicine, All India Institute of Medical Sciences Patna, Patna, Bihar, IndiaSchool of Pharmacy, University College London, London, UK3 Helix Centre for Design in Healthcare, Imperial College London, London, UKIntroduction Medication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.Objectives To describe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contribution of discrepancies in individual process steps to the occurrence of these errors.Methods We conducted a prospective observational study of simulated resuscitations subjected to video microanalysis, identification of medication errors, severity assessment and human reliability analysis in a large English teaching hospital. Fifteen resuscitation teams of two doctors and two nurses each conducted one of two simulated paediatric resuscitation scenarios.Results At least one medication error was observed in every simulated case, and a large magnitude (>25% discrepant) or clinically significant error in 11 of 15 cases. Medication errors were observed in 29% of 180 simulated medication administrations, 40% of which considered to be moderate or severe. These errors were the result of 884 observed discrepancies at a number of steps in the drug ordering, preparation and administration stages of medication use, 8% of which made a major contribution to a resultant medication error. Most errors were introduced by discrepancies during drug preparation and administration.Conclusions Medication errors were common with a considerable proportion likely to result in patient harm. There is an urgent need to optimise existing systems and to commission research into new approaches to increase the reliability of human interactions during administration of medication in the paediatric emergency setting.https://bmjopen.bmj.com/content/9/11/e032686.full |
| spellingShingle | Ruchi Sinha Bryony Franklin Phillip Pratt Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis BMJ Open |
| title | Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis |
| title_full | Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis |
| title_fullStr | Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis |
| title_full_unstemmed | Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis |
| title_short | Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis |
| title_sort | medication errors during simulated paediatric resuscitations a prospective observational human reliability analysis |
| url | https://bmjopen.bmj.com/content/9/11/e032686.full |
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