SP5 Tenfold medication errors in children – Welsh paediatric surveillance unit study 2017–9

AimsTo establish the incidence and characteristics of tenfold or greater and a tenth or less medication errors in children

Saved in:
Bibliographic Details
Published in:Archives of disease in childhood 2020-09, Vol.105 (9), p.e3.1-e3
Main Authors: Tse, Yincent, Tuthill, David
Format: Article
Language:English
Subjects:
Children
Dosage
Drugs
Hospitals
Human factors
Intravenous administration
Medical errors
Patients
Pediatrics
Pharmacists
Population studies
Surveillance
Citations: Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
cited_by cdi_FETCH-LOGICAL-c1825-60c38c1b109da4631278541a44287bb5e4dee81431aba4cdad319b5662db88bd3
cites
container_end_page e3
container_issue 9
container_start_page e3.1
container_title Archives of disease in childhood
container_volume 105
creator Tse, Yincent
Tuthill, David
description AimsTo establish the incidence and characteristics of tenfold or greater and a tenth or less medication errors in children
doi_str_mv 10.1136/archdischild-2020-NPPG.5
format article
fullrecord <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_journals_2435389655</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2435389655</sourcerecordid><originalsourceid>FETCH-LOGICAL-c1825-60c38c1b109da4631278541a44287bb5e4dee81431aba4cdad319b5662db88bd3</originalsourceid><addsrcrecordid>eNpNkM1KAzEUhYMoWKvvEHA9NTc_0ztLKVqFogUrLkMmSWnKdKYmM0J3bnwC37BP4tS6cHXg8t1z4COEAhsBiPzGRLtyIdlVqFzGGWfZ03w-HakTMgCZY3-S8pQMGGMiKxDxnFyktGYMOKIYEPMyV_vPr4Wvl03l6Ma7YE0bmpr6GJuYaKjpb3f0Nd1_ftM3X6UV3ZoeNG0MlqYufvhQVaa2nnZ1aGlqO7ejnMG4fyguydnSVMlf_eWQvN7fLSYP2ex5-ji5nWUWkKssZ1aghRJY4YzMBfAxKglGSo7jslReOu8RpABTGmmdcQKKUuU5dyVi6cSQXB97t7F573xq9brpYt1Pai6FEljkSvUUHikbm5SiX-ptDBsTdxqYPgjV_4Xqg1B9EKqV-AEECnBY</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2435389655</pqid></control><display><type>article</type><title>SP5 Tenfold medication errors in children – Welsh paediatric surveillance unit study 2017–9</title><source>Social Science Premium Collection</source><source>Education Collection</source><creator>Tse, Yincent ; Tuthill, David</creator><creatorcontrib>Tse, Yincent ; Tuthill, David</creatorcontrib><description>AimsTo establish the incidence and characteristics of tenfold or greater and a tenth or less medication errors in children &lt;16 years in Wales to help inform patient safety on a population level.MethodPopulation-based incidence study in Wales, UK, from June 2017 - May 2019 (24 months). Cases were reported from paediatricians and hospital pharmacists using the monthly Welsh Paediatric Surveillance Unit (WPSU).Results46 confirmed incidents in 44 children from 63 notifications were identified. Cases came from 8 hospitals in Wales with 29 (63%) from the sole tertiary hospital. Median age was 1.7 (range 1 week to 15) years and weight 10 kg (0.6 to 59).39 (85%) were overdosing (up to 1000x fold error) and 7 underdosing. 40 different medications were involved, 16 (37%) intravenous. Of 29 cases involving enteral medication, 26 (90%) were liquid formulations. Three cases were discharge medication prescribed or dispensed incorrectly and administrated at home. Stage of errors were primarily in prescribing 37 (80%), administration 7 (16%) and dispensing 2 (4%).18 (42%) cases reached the patient, 10 from prescribing. Seven cases were spotted after multiple doses were given. Six errors resulted in harm, three which required intensive care treatment. No deaths or permanent disabilities were reported. Half (23/46) of all errors reported and two-thirds (12/18) of cases that reached the child occurred in &lt;10 kg children.Several human factor themes were identified: Prescribing confusion between gram milligram and microgram (none reached patient, n=7), confusing between mg and mg/kg (n=6 including 3 underdosing errors), leading zero errors (e.g. 0.1 vs 0.001 mg, n=6) and prescribing reconciliation errors where admitting doctor attempted to prescribe chronic medication in mg by reversing calculating liquid dosage expressed in mL (n=4).During this study period 164,000 hospital admissions occurred in children &lt;16 years in Wales. Our data estimates a tenfold error incidence of 1:3600 paediatric admissions, with drug reaching the child in 1:9000 admissions.ConclusionIn this unique first ever population surveillance study, tenfold errors in children occurred at every stage of medication process and in the full range of care settings. Errors found were very different from those obtained from tertiary hospital single centre study and UK National Reporting and Learning System (NRLS). Strategies for error reduction will be more productive if designed across a whole national healthcare system.</description><identifier>ISSN: 0003-9888</identifier><identifier>EISSN: 1468-2044</identifier><identifier>DOI: 10.1136/archdischild-2020-NPPG.5</identifier><language>eng</language><publisher>London: BMJ Publishing Group LTD</publisher><subject>Children ; Dosage ; Drugs ; Hospitals ; Human factors ; Intravenous administration ; Medical errors ; Patients ; Pediatrics ; Pharmacists ; Population studies ; Surveillance</subject><ispartof>Archives of disease in childhood, 2020-09, Vol.105 (9), p.e3.1-e3</ispartof><rights>2020 Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c1825-60c38c1b109da4631278541a44287bb5e4dee81431aba4cdad319b5662db88bd3</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.proquest.com/docview/2435389655/fulltextPDF?pq-origsite=primo$$EPDF$$P50$$Gproquest$$H</linktopdf><linktohtml>$$Uhttps://www.proquest.com/docview/2435389655?pq-origsite=primo$$EHTML$$P50$$Gproquest$$H</linktohtml><link.rule.ids>314,776,780,21358,21374,27903,27904,33590,33856,43712,43859,73967,74143</link.rule.ids></links><search><creatorcontrib>Tse, Yincent</creatorcontrib><creatorcontrib>Tuthill, David</creatorcontrib><title>SP5 Tenfold medication errors in children – Welsh paediatric surveillance unit study 2017–9</title><title>Archives of disease in childhood</title><description>AimsTo establish the incidence and characteristics of tenfold or greater and a tenth or less medication errors in children &lt;16 years in Wales to help inform patient safety on a population level.MethodPopulation-based incidence study in Wales, UK, from June 2017 - May 2019 (24 months). Cases were reported from paediatricians and hospital pharmacists using the monthly Welsh Paediatric Surveillance Unit (WPSU).Results46 confirmed incidents in 44 children from 63 notifications were identified. Cases came from 8 hospitals in Wales with 29 (63%) from the sole tertiary hospital. Median age was 1.7 (range 1 week to 15) years and weight 10 kg (0.6 to 59).39 (85%) were overdosing (up to 1000x fold error) and 7 underdosing. 40 different medications were involved, 16 (37%) intravenous. Of 29 cases involving enteral medication, 26 (90%) were liquid formulations. Three cases were discharge medication prescribed or dispensed incorrectly and administrated at home. Stage of errors were primarily in prescribing 37 (80%), administration 7 (16%) and dispensing 2 (4%).18 (42%) cases reached the patient, 10 from prescribing. Seven cases were spotted after multiple doses were given. Six errors resulted in harm, three which required intensive care treatment. No deaths or permanent disabilities were reported. Half (23/46) of all errors reported and two-thirds (12/18) of cases that reached the child occurred in &lt;10 kg children.Several human factor themes were identified: Prescribing confusion between gram milligram and microgram (none reached patient, n=7), confusing between mg and mg/kg (n=6 including 3 underdosing errors), leading zero errors (e.g. 0.1 vs 0.001 mg, n=6) and prescribing reconciliation errors where admitting doctor attempted to prescribe chronic medication in mg by reversing calculating liquid dosage expressed in mL (n=4).During this study period 164,000 hospital admissions occurred in children &lt;16 years in Wales. Our data estimates a tenfold error incidence of 1:3600 paediatric admissions, with drug reaching the child in 1:9000 admissions.ConclusionIn this unique first ever population surveillance study, tenfold errors in children occurred at every stage of medication process and in the full range of care settings. Errors found were very different from those obtained from tertiary hospital single centre study and UK National Reporting and Learning System (NRLS). Strategies for error reduction will be more productive if designed across a whole national healthcare system.</description><subject>Children</subject><subject>Dosage</subject><subject>Drugs</subject><subject>Hospitals</subject><subject>Human factors</subject><subject>Intravenous administration</subject><subject>Medical errors</subject><subject>Patients</subject><subject>Pediatrics</subject><subject>Pharmacists</subject><subject>Population studies</subject><subject>Surveillance</subject><issn>0003-9888</issn><issn>1468-2044</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>ALSLI</sourceid><sourceid>CJNVE</sourceid><sourceid>M0P</sourceid><recordid>eNpNkM1KAzEUhYMoWKvvEHA9NTc_0ztLKVqFogUrLkMmSWnKdKYmM0J3bnwC37BP4tS6cHXg8t1z4COEAhsBiPzGRLtyIdlVqFzGGWfZ03w-HakTMgCZY3-S8pQMGGMiKxDxnFyktGYMOKIYEPMyV_vPr4Wvl03l6Ma7YE0bmpr6GJuYaKjpb3f0Nd1_ftM3X6UV3ZoeNG0MlqYufvhQVaa2nnZ1aGlqO7ejnMG4fyguydnSVMlf_eWQvN7fLSYP2ex5-ji5nWUWkKssZ1aghRJY4YzMBfAxKglGSo7jslReOu8RpABTGmmdcQKKUuU5dyVi6cSQXB97t7F573xq9brpYt1Pai6FEljkSvUUHikbm5SiX-ptDBsTdxqYPgjV_4Xqg1B9EKqV-AEECnBY</recordid><startdate>202009</startdate><enddate>202009</enddate><creator>Tse, Yincent</creator><creator>Tuthill, David</creator><general>BMJ Publishing Group LTD</general><scope>AAYXX</scope><scope>CITATION</scope><scope>0-V</scope><scope>3V.</scope><scope>7X7</scope><scope>7XB</scope><scope>88B</scope><scope>88E</scope><scope>88I</scope><scope>8A4</scope><scope>8AF</scope><scope>8FE</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AEUYN</scope><scope>AFKRA</scope><scope>ALSLI</scope><scope>AN0</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BHPHI</scope><scope>BTHHO</scope><scope>CCPQU</scope><scope>CJNVE</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>HCIFZ</scope><scope>K9-</scope><scope>K9.</scope><scope>LK8</scope><scope>M0P</scope><scope>M0R</scope><scope>M0S</scope><scope>M1P</scope><scope>M2P</scope><scope>M7P</scope><scope>PQEDU</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>Q9U</scope></search><sort><creationdate>202009</creationdate><title>SP5 Tenfold medication errors in children – Welsh paediatric surveillance unit study 2017–9</title><author>Tse, Yincent ; Tuthill, David</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c1825-60c38c1b109da4631278541a44287bb5e4dee81431aba4cdad319b5662db88bd3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Children</topic><topic>Dosage</topic><topic>Drugs</topic><topic>Hospitals</topic><topic>Human factors</topic><topic>Intravenous administration</topic><topic>Medical errors</topic><topic>Patients</topic><topic>Pediatrics</topic><topic>Pharmacists</topic><topic>Population studies</topic><topic>Surveillance</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Tse, Yincent</creatorcontrib><creatorcontrib>Tuthill, David</creatorcontrib><collection>CrossRef</collection><collection>ProQuest Social Sciences Premium Collection【Remote access available】</collection><collection>ProQuest Central (Corporate)</collection><collection>ProQuest Health &amp; Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Education Database (Alumni Edition)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Science Database (Alumni Edition)</collection><collection>Education Periodicals</collection><collection>STEM Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni)</collection><collection>ProQuest One Sustainability</collection><collection>ProQuest Central</collection><collection>Social Science Premium Collection</collection><collection>British Nursing Database</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>ProQuest Natural Science Collection</collection><collection>BMJ Journals</collection><collection>ProQuest One Community College</collection><collection>Education Collection</collection><collection>ProQuest Central</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>SciTech Premium Collection</collection><collection>Consumer Health Database (Alumni Edition)</collection><collection>ProQuest Health &amp; Medical Complete (Alumni)</collection><collection>Biological Sciences</collection><collection>ProQuest Education Journals</collection><collection>ProQuest Consumer Health Database</collection><collection>Health &amp; Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>ProQuest Science Journals</collection><collection>Biological Science Database</collection><collection>ProQuest One Education</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central Basic</collection><jtitle>Archives of disease in childhood</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Tse, Yincent</au><au>Tuthill, David</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>SP5 Tenfold medication errors in children – Welsh paediatric surveillance unit study 2017–9</atitle><jtitle>Archives of disease in childhood</jtitle><date>2020-09</date><risdate>2020</risdate><volume>105</volume><issue>9</issue><spage>e3.1</spage><epage>e3</epage><pages>e3.1-e3</pages><issn>0003-9888</issn><eissn>1468-2044</eissn><abstract>AimsTo establish the incidence and characteristics of tenfold or greater and a tenth or less medication errors in children &lt;16 years in Wales to help inform patient safety on a population level.MethodPopulation-based incidence study in Wales, UK, from June 2017 - May 2019 (24 months). Cases were reported from paediatricians and hospital pharmacists using the monthly Welsh Paediatric Surveillance Unit (WPSU).Results46 confirmed incidents in 44 children from 63 notifications were identified. Cases came from 8 hospitals in Wales with 29 (63%) from the sole tertiary hospital. Median age was 1.7 (range 1 week to 15) years and weight 10 kg (0.6 to 59).39 (85%) were overdosing (up to 1000x fold error) and 7 underdosing. 40 different medications were involved, 16 (37%) intravenous. Of 29 cases involving enteral medication, 26 (90%) were liquid formulations. Three cases were discharge medication prescribed or dispensed incorrectly and administrated at home. Stage of errors were primarily in prescribing 37 (80%), administration 7 (16%) and dispensing 2 (4%).18 (42%) cases reached the patient, 10 from prescribing. Seven cases were spotted after multiple doses were given. Six errors resulted in harm, three which required intensive care treatment. No deaths or permanent disabilities were reported. Half (23/46) of all errors reported and two-thirds (12/18) of cases that reached the child occurred in &lt;10 kg children.Several human factor themes were identified: Prescribing confusion between gram milligram and microgram (none reached patient, n=7), confusing between mg and mg/kg (n=6 including 3 underdosing errors), leading zero errors (e.g. 0.1 vs 0.001 mg, n=6) and prescribing reconciliation errors where admitting doctor attempted to prescribe chronic medication in mg by reversing calculating liquid dosage expressed in mL (n=4).During this study period 164,000 hospital admissions occurred in children &lt;16 years in Wales. Our data estimates a tenfold error incidence of 1:3600 paediatric admissions, with drug reaching the child in 1:9000 admissions.ConclusionIn this unique first ever population surveillance study, tenfold errors in children occurred at every stage of medication process and in the full range of care settings. Errors found were very different from those obtained from tertiary hospital single centre study and UK National Reporting and Learning System (NRLS). Strategies for error reduction will be more productive if designed across a whole national healthcare system.</abstract><cop>London</cop><pub>BMJ Publishing Group LTD</pub><doi>10.1136/archdischild-2020-NPPG.5</doi><oa>free_for_read</oa></addata></record>
fulltext fulltext
identifier ISSN: 0003-9888
ispartof Archives of disease in childhood, 2020-09, Vol.105 (9), p.e3.1-e3
issn 0003-9888
1468-2044
language eng
recordid cdi_proquest_journals_2435389655
source Social Science Premium Collection; Education Collection
subjects Children
Dosage
Drugs
Hospitals
Human factors
Intravenous administration
Medical errors
Patients
Pediatrics
Pharmacists
Population studies
Surveillance
title SP5 Tenfold medication errors in children – Welsh paediatric surveillance unit study 2017–9
url http://sfxeu10.hosted.exlibrisgroup.com/loughborough?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-26T03%3A28%3A27IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=SP5%E2%80%85Tenfold%20medication%20errors%20in%20children%20%E2%80%93%20Welsh%20paediatric%20surveillance%20unit%20study%202017%E2%80%939&rft.jtitle=Archives%20of%20disease%20in%20childhood&rft.au=Tse,%20Yincent&rft.date=2020-09&rft.volume=105&rft.issue=9&rft.spage=e3.1&rft.epage=e3&rft.pages=e3.1-e3&rft.issn=0003-9888&rft.eissn=1468-2044&rft_id=info:doi/10.1136/archdischild-2020-NPPG.5&rft_dat=%3Cproquest_cross%3E2435389655%3C/proquest_cross%3E%3Cgrp_id%3Ecdi_FETCH-LOGICAL-c1825-60c38c1b109da4631278541a44287bb5e4dee81431aba4cdad319b5662db88bd3%3C/grp_id%3E%3Coa%3E%3C/oa%3E%3Curl%3E%3C/url%3E&rft_id=info:oai/&rft_pqid=2435389655&rft_id=info:pmid/&rfr_iscdi=true