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Patient safety

How to prevent pediatric medication errors?

TORONTO – Medication errors are occurring frequently on pediatric wards, with “devastating” impact on children and their families, concludes a new survey of Canadian hospitals that found four deaths over the three-month span studied, and an average of 20 drug-administration mistakes per hospital ward.

“I saw four lethal errors, which doesn’t seem like very much, but that’s four children who died,” Kim Sears (pictured), a Queen’s University nursing professor and the lead researcher, noted in an interview with the National Post newspaper. “Each site had at least one child die in it during the three months, because of a medication … I had only 18 [hospital wards] in total. That’s a very small sample.”

While many of the mix-ups were near-misses, 14% were potentially lethal, the survey of nursing staff found, adding to a growing body of knowledge on the harm inadvertently done to patients in hospital.

Nurses who took part in the anonymous survey in three provinces were most likely to blame heavy workload, distraction and poor communication for the mistakes, said the study that was recently published in the Journal of Pediatric Nursing.

As solutions to the problem, the article urges better-designed work spaces, improved communication between staff, and more widespread pediatric training for nurses to curb the rate of mistakes.

Though the research was conducted a few years ago – but only published this month – Prof. Sears said she believes the issues remain largely unchanged.

One expert in the field said the findings do not seem surprising, but stressed that hospitals are working hard to alleviate some of the problems. “We’re tackling this as best as we can,” said Christine Koczmara, a senior analyst with the Institute for Safe Medication Practices.

A Canadian study published last year concluded that close to 10% of the child patients it reviewed at 22 hospitals had suffered adverse events, with medication-related incidents ranked as the second-largest source of problems behind surgery.

Prof. Sears’ research, however, may be the first in Canada to look specifically at the key area of medication administration for pediatric patients, giving a more graphic picture of how problems occur.

Errors are occurring frequently and are ultimately devastating to children and their families. The ramifications of an error are overwhelming and can have a profound impact on the nurse, patient and system The potential for disaster is greater with child patients, given that nurses often have to mix up the medication at the bedside, quantities of drugs are so small that a dangerously large dose may not be readily noticeable, and widely varying body sizes require careful calculation of dosages, said Prof. Sears.

Her study had nurses working on a total of 440 patient beds at three hospitals – in eastern, central and western Canada – fill out anonymous forms when a mistake happened while giving drugs to patients.

The survey recorded 372 errors over the three months, including 127 near misses where the mishap was caught before the child received their medication, and 245 actual errors.

As well as the four deaths, 51 were graded as potentially lethal, 20 as serious, 112 as significant and 185 minimal.

Giving children their medication at the wrong time – instead of within the recommended half-hour window to avoid incorrect dosing – was the most common slip-up, followed by administering the wrong dose, and feeding patients the incorrect drug, the study found.

“[Errors] are occurring frequently and are ultimately devastating to children and their families,” the paper says. “The ramifications of an error are overwhelming and can have a profound impact on the nurse, patient and system.”

Prof. Sears said nurses need bigger, better-lit spaces in which to prepare medications, and face fewer distractions from other staff. Some nursing schools also do not offer pediatric rotations, despite the popularity of the work within the profession, she said.

“So [nurses] end up at a children’s hospital, but they haven’t had much experience with children. That’s kind of scary.”

Ms. Koczmara confirmed that distraction of professionals as they administer drugs is a well-documented problem that the system is trying to alleviate.

Some hospitals have even experimented with having staff wear jackets of a particular colour that indicate to co-workers they are at a crucial point in treating a patient and should not be distracted, said Ms. Koczmara.

Posted January 24, 2013