Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns

• Published in: European journal of pediatrics 2019-02, Vol.178 (2), p.259-266
• Main Authors: Palmero, David, Di Paolo, Ermindo R., Stadelmann, Corinne, Pannatier, André, Sadeghipour, Farshid, Tolsa, Jean-François
• Format: Article
• Language: English
• Subjects: Attention; Caregivers; Gestational age; Hospitalization - statistics & numerical data; Hospitals; Human error; Humans; Infant, Newborn; Intensive Care Units, Neonatal - standards; Intensive Care Units, Neonatal - statistics & numerical data; Medical errors; Medication Errors - statistics & numerical data; Medicine; Medicine & Public Health; Neonates; Newborn babies; Original Article; Pediatrics; Pharmacists; Quality control; Risk Factors; Risk Management - methods; Switzerland; Watchful Waiting - methods
• ISSN: 0340-6199; 1432-1076
• DOI: 10.1007/s00431-018-3294-8

Newborns are often exposed to medication errors in hospitals. Identification and understanding the causes and risk factors associated with medication errors will help to improve the effectiveness of medication. We sought to compare voluntary incident reports and direct observation in the identification of medication errors. We also identified corresponding risk factors in order to establish measures to prevent medication errors. Medication errors identified by a clinical pharmacist and those recorded in our incident reporting system by caregivers were analysed. Main outcomes were rates, type and severity of medication error, and other variables related to medication errors. Ultimately, 383 medication errors were identified by the clinical pharmacist, and two medication errors were declared by caregivers. Prescription errors accounted for 38.4%, preparation errors for 16.2%, and administration errors for 45.4%. The two variables significantly related to the occurrence of medication errors were gestational age