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Circumstances of 10-fold pediatric medication errors examined
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Opioids were the most commonly misdosed class of medication, according to results of a review study from the Hospital for Sick Children in Toronto.
Catherine Doherty, MB, and colleagues from the department of anesthesia and pain medicine reviewed 252 10-fold medication errors from the hospital’s Voluntary Safety Patient Reporting Database between June 2004 and July 2009.
Doherty and colleagues said 22 of these 10-fold errors resulted in patient harm, and the highest incidence of medication error was for morphine. This confirms prior studies of high-risk drugs, the researchers wrote. Opioids, in general, had the highest incidence of error for drug class; study data also showed that antibiotics were often prescribed at one-tenth of the effective dose.
Computerized physician order entry was considered a contributor to 10-fold medication errors “because of the overriding of recommendations, ignoring of alerts, and an inability to recognize certain 10-fold underdoses,” according to the study findings.
In addition, Doherty and colleagues said a risk of error occurred with IV formulations of medications. Ordered paper prescriptions also were a factor, besides improperly programmed drug-delivery pumps.
“Paper-based ordering is associated with illegibility and errors of misinterpretation, errors involving decimal points, and errors involving multiple and/or trailing zeroes,” the researchers said.
Avoiding distraction, particularly while performing duties such as prescribing and administering medications, is essential, but there is no simple resolution, they said.
“No single solution can be implemented to successfully combat the complex multifactorial issues described in the results we present; however, these results do give us some guidance as regards where future efforts may best be directed,” the researchers concluded.
Disclosure: Ms. Doherty reports no relevant financial disclosures.
Perspective
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Edward A. Bell, PharmD, BCPS
This study by Doherty provides useful information on medication errors, specifically 10-fold errors, in the pediatric population. As few data have been previously available on medication errors in pediatrics, this study is welcomed. We do know, however, that dosing errors are the most commonly occurring medication error in pediatrics. Less is known about how these errors occur, and methods to reduce their occurrence. The authors retrospectively assessed all medication-related incident reports of 10-fold medication errors from a safety-reporting database over a 5-year period at a large pediatric hospital in Toronto. Over this period, 6,433 medication-related safety reports were identified, of which 252 involved 10-fold errors. Of these, 125 errors directly affected the patient and 22 incidences of patient harm were identified. Drug classes most commonly involved with errors included opioid analgesics, antimicrobials and anticoagulants.
The authors carefully assessed the complexity of medication error occurrence, and identified error sources, mechanisms and enablers. In doing so, it becomes evident that medication error occurrence can involve a variety of contributing factors, including computerized physician order entry, dosing calculations and medication administration factors. In recognizing the differing parts of the medication use process in pediatrics that can lead to significant error, and patient harm, this study provides useful data on potential methods to increase the safe use of medications in infants and children.
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