Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents
Abstract Background Paediatric patients are prone to medication errors, but an in-depth understanding of errors involving high-alert medications remains limited. Objective We aimed to investigate incident reports involving high-alert medications to describe medication errors, error chains and stages...
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| Format: | Article |
| Language: | English |
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Adis, Springer Healthcare
2024-12-01
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| Series: | Drugs - Real World Outcomes |
| Online Access: | https://doi.org/10.1007/s40801-024-00469-4 |
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| author | Sini Kuitunen Mari Saksa Anna-Riia Holmström |
| author_facet | Sini Kuitunen Mari Saksa Anna-Riia Holmström |
| author_sort | Sini Kuitunen |
| collection | DOAJ |
| description | Abstract Background Paediatric patients are prone to medication errors, but an in-depth understanding of errors involving high-alert medications remains limited. Objective We aimed to investigate incident reports involving high-alert medications to describe medication errors, error chains and stages of the medication management and use process where the errors occur in paediatric hospitals. Methods A retrospective document analysis of self-reported medication safety incidents in a paediatric university hospital in 2018–20. The incident reports involving high-alert medications were investigated using an inductive qualitative content analysis and quantified (frequencies and percentages). A systems approach to medication risk management based on the Theory of Human Error was applied. Results Altogether, 560 medication errors were identified within the study sample (n = 426 incident reports). Most medication errors were associated with administration (43.1 %, n = 241/560) and prescribing (25.2 %, n = 141/560). Error chains involving two to four medication errors in one or more stages of the medication management and use process were present in 26.1% (n = 111/426) of reports, most of which originated from prescribing (62.2%; n = 69/111). The medication errors (n = 560) were classified into 14 main categories, the most common of which were wrong dose (13.9%; n = 78/560), omission of a drug (12.9%; n = 72/560) and documentation errors (10.0%; n = 56). Conclusions Paediatric medication error chains often start from prescribing and pass through the medication management and use process. Systemic defences are especially needed for manual tasks leading to wrong doses, drug omission and documentation errors. Intravenous medications and chemotherapeutic agents, optimising drug formularies and handling, and high-alert drug use at home require further actions in paediatric medication risk management. |
| format | Article |
| id | doaj-art-6feb5d2284d04cfaa24e4d0a6bd71d53 |
| institution | OA Journals |
| issn | 2199-1154 2198-9788 |
| language | English |
| publishDate | 2024-12-01 |
| publisher | Adis, Springer Healthcare |
| record_format | Article |
| series | Drugs - Real World Outcomes |
| spelling | doaj-art-6feb5d2284d04cfaa24e4d0a6bd71d532025-08-20T02:13:07ZengAdis, Springer HealthcareDrugs - Real World Outcomes2199-11542198-97882024-12-01121456110.1007/s40801-024-00469-4Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety IncidentsSini Kuitunen0Mari Saksa1Anna-Riia Holmström2Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of HelsinkiDivision of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of HelsinkiDivision of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of HelsinkiAbstract Background Paediatric patients are prone to medication errors, but an in-depth understanding of errors involving high-alert medications remains limited. Objective We aimed to investigate incident reports involving high-alert medications to describe medication errors, error chains and stages of the medication management and use process where the errors occur in paediatric hospitals. Methods A retrospective document analysis of self-reported medication safety incidents in a paediatric university hospital in 2018–20. The incident reports involving high-alert medications were investigated using an inductive qualitative content analysis and quantified (frequencies and percentages). A systems approach to medication risk management based on the Theory of Human Error was applied. Results Altogether, 560 medication errors were identified within the study sample (n = 426 incident reports). Most medication errors were associated with administration (43.1 %, n = 241/560) and prescribing (25.2 %, n = 141/560). Error chains involving two to four medication errors in one or more stages of the medication management and use process were present in 26.1% (n = 111/426) of reports, most of which originated from prescribing (62.2%; n = 69/111). The medication errors (n = 560) were classified into 14 main categories, the most common of which were wrong dose (13.9%; n = 78/560), omission of a drug (12.9%; n = 72/560) and documentation errors (10.0%; n = 56). Conclusions Paediatric medication error chains often start from prescribing and pass through the medication management and use process. Systemic defences are especially needed for manual tasks leading to wrong doses, drug omission and documentation errors. Intravenous medications and chemotherapeutic agents, optimising drug formularies and handling, and high-alert drug use at home require further actions in paediatric medication risk management.https://doi.org/10.1007/s40801-024-00469-4 |
| spellingShingle | Sini Kuitunen Mari Saksa Anna-Riia Holmström Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents Drugs - Real World Outcomes |
| title | Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents |
| title_full | Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents |
| title_fullStr | Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents |
| title_full_unstemmed | Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents |
| title_short | Medication Errors and Error Chains Involving High-Alert Medications in a Paediatric Hospital Setting: A Qualitative Analysis of Self-Reported Medication Safety Incidents |
| title_sort | medication errors and error chains involving high alert medications in a paediatric hospital setting a qualitative analysis of self reported medication safety incidents |
| url | https://doi.org/10.1007/s40801-024-00469-4 |
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