Loading…
Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns
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 identificat...
Saved in:
| Published in: | European journal of pediatrics 2019-02, Vol.178 (2), p.259-266 |
|---|---|
| Main Authors: | , , , , , |
| Format: | Article |
| Language: | English |
| Subjects: | |
| Citations: | Items that this one cites 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-c372t-6cd4f64d6f5f05186f2be1afe6a9d9137e3eceac966dad3d681712e3e38c13e3 |
|---|---|
| cites | cdi_FETCH-LOGICAL-c372t-6cd4f64d6f5f05186f2be1afe6a9d9137e3eceac966dad3d681712e3e38c13e3 |
| container_end_page | 266 |
| container_issue | 2 |
| container_start_page | 259 |
| container_title | European journal of pediatrics |
| container_volume | 178 |
| creator | Palmero, David Di Paolo, Ermindo R. Stadelmann, Corinne Pannatier, André Sadeghipour, Farshid Tolsa, Jean-François |
| description | 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 |
| doi_str_mv | 10.1007/s00431-018-3294-8 |
| format | article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_2136550698</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2135819172</sourcerecordid><originalsourceid>FETCH-LOGICAL-c372t-6cd4f64d6f5f05186f2be1afe6a9d9137e3eceac966dad3d681712e3e38c13e3</originalsourceid><addsrcrecordid>eNp1kcFuFSEUhonR2Gv1AdwYEjduRjnDDDMsTVO1SRM33RMuHJR6L1w5TE3fXsapmpi4geTnOz-Ej7GXIN6CENM7EmKQ0AmYO9nroZsfsR0Msu9ATOox2wk5iE6B1mfsGdGtaDMa5qfsTIpBiUFMO1aukoseU-UFT7lU4ndYaCHuY0FXed4TljtbY068Zv4LjeGeH9FHt8VYSi7EbfK8RPrGg3V1DWLiXzOdYrWHSOh5wh_7XBI9Z0-CPRC-eNjP2c2Hy5uLT931549XF--vOyenvnbK-SGowaswBjHCrEK_R7ABldVeg5xQokPrtFLeeunVDBP0LZSzg7aeszdb7ank7wtSNcdIDg8HmzAvZHqQahyF0nNDX_-D3ualpPa4lRpn0DD1jYKNciUTFQzmVOLRlnsDwqw-zObDNB9m9WHW5lcPzcu-fdmfid8CGtBvALWj9AXL36v_3_oTmCSYLQ</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2135819172</pqid></control><display><type>article</type><title>Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns</title><source>Springer Nature</source><creator>Palmero, David ; Di Paolo, Ermindo R. ; Stadelmann, Corinne ; Pannatier, André ; Sadeghipour, Farshid ; Tolsa, Jean-François</creator><creatorcontrib>Palmero, David ; Di Paolo, Ermindo R. ; Stadelmann, Corinne ; Pannatier, André ; Sadeghipour, Farshid ; Tolsa, Jean-François</creatorcontrib><description>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 < 32.0 weeks (
p
= 0.04) and the number of drugs prescribed (
p
< 0.01).
Conclusion
: Caregivers underreported the true rate of medication errors. Most medication errors were caused by inattention and could have been limited by simplifying the medication process. Risk of medication errors is increased in newborns < 32.0 weeks and increases with the number of drugs prescribed to each patient.
What is Known:
•
Newborns in hospitals are particularly susceptible to medication errors.
•
Identification and understanding the reasons for medication errors should help us to establish preventive measures to reduce the occurrence of such errors.
What is New:
•
Direct observation of the medication process, though time consuming, is essential to accurately assess the frequency of medication errors, which are underreported by caregivers. Most medication errors are caused by inattention and could be limited by simplifying the medication process.
•
The risk of medication errors was significantly increased in very preterm newborns (< 32 weeks) and when the number of prescription per patient increased.</description><identifier>ISSN: 0340-6199</identifier><identifier>EISSN: 1432-1076</identifier><identifier>DOI: 10.1007/s00431-018-3294-8</identifier><identifier>PMID: 30460407</identifier><language>eng</language><publisher>Berlin/Heidelberg: Springer Berlin Heidelberg</publisher><subject>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</subject><ispartof>European journal of pediatrics, 2019-02, Vol.178 (2), p.259-266</ispartof><rights>Springer-Verlag GmbH Germany, part of Springer Nature 2018</rights><rights>European Journal of Pediatrics is a copyright of Springer, (2018). All Rights Reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c372t-6cd4f64d6f5f05186f2be1afe6a9d9137e3eceac966dad3d681712e3e38c13e3</citedby><cites>FETCH-LOGICAL-c372t-6cd4f64d6f5f05186f2be1afe6a9d9137e3eceac966dad3d681712e3e38c13e3</cites><orcidid>0000-0002-2813-4487</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,777,781,27905,27906</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30460407$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Palmero, David</creatorcontrib><creatorcontrib>Di Paolo, Ermindo R.</creatorcontrib><creatorcontrib>Stadelmann, Corinne</creatorcontrib><creatorcontrib>Pannatier, André</creatorcontrib><creatorcontrib>Sadeghipour, Farshid</creatorcontrib><creatorcontrib>Tolsa, Jean-François</creatorcontrib><title>Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns</title><title>European journal of pediatrics</title><addtitle>Eur J Pediatr</addtitle><addtitle>Eur J Pediatr</addtitle><description>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 < 32.0 weeks (
p
= 0.04) and the number of drugs prescribed (
p
< 0.01).
Conclusion
: Caregivers underreported the true rate of medication errors. Most medication errors were caused by inattention and could have been limited by simplifying the medication process. Risk of medication errors is increased in newborns < 32.0 weeks and increases with the number of drugs prescribed to each patient.
What is Known:
•
Newborns in hospitals are particularly susceptible to medication errors.
•
Identification and understanding the reasons for medication errors should help us to establish preventive measures to reduce the occurrence of such errors.
What is New:
•
Direct observation of the medication process, though time consuming, is essential to accurately assess the frequency of medication errors, which are underreported by caregivers. Most medication errors are caused by inattention and could be limited by simplifying the medication process.
•
The risk of medication errors was significantly increased in very preterm newborns (< 32 weeks) and when the number of prescription per patient increased.</description><subject>Attention</subject><subject>Caregivers</subject><subject>Gestational age</subject><subject>Hospitalization - statistics & numerical data</subject><subject>Hospitals</subject><subject>Human error</subject><subject>Humans</subject><subject>Infant, Newborn</subject><subject>Intensive Care Units, Neonatal - standards</subject><subject>Intensive Care Units, Neonatal - statistics & numerical data</subject><subject>Medical errors</subject><subject>Medication Errors - statistics & numerical data</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Neonates</subject><subject>Newborn babies</subject><subject>Original Article</subject><subject>Pediatrics</subject><subject>Pharmacists</subject><subject>Quality control</subject><subject>Risk Factors</subject><subject>Risk Management - methods</subject><subject>Switzerland</subject><subject>Watchful Waiting - methods</subject><issn>0340-6199</issn><issn>1432-1076</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><recordid>eNp1kcFuFSEUhonR2Gv1AdwYEjduRjnDDDMsTVO1SRM33RMuHJR6L1w5TE3fXsapmpi4geTnOz-Ej7GXIN6CENM7EmKQ0AmYO9nroZsfsR0Msu9ATOox2wk5iE6B1mfsGdGtaDMa5qfsTIpBiUFMO1aukoseU-UFT7lU4ndYaCHuY0FXed4TljtbY068Zv4LjeGeH9FHt8VYSi7EbfK8RPrGg3V1DWLiXzOdYrWHSOh5wh_7XBI9Z0-CPRC-eNjP2c2Hy5uLT931549XF--vOyenvnbK-SGowaswBjHCrEK_R7ABldVeg5xQokPrtFLeeunVDBP0LZSzg7aeszdb7ank7wtSNcdIDg8HmzAvZHqQahyF0nNDX_-D3ualpPa4lRpn0DD1jYKNciUTFQzmVOLRlnsDwqw-zObDNB9m9WHW5lcPzcu-fdmfid8CGtBvALWj9AXL36v_3_oTmCSYLQ</recordid><startdate>20190201</startdate><enddate>20190201</enddate><creator>Palmero, David</creator><creator>Di Paolo, Ermindo R.</creator><creator>Stadelmann, Corinne</creator><creator>Pannatier, André</creator><creator>Sadeghipour, Farshid</creator><creator>Tolsa, Jean-François</creator><general>Springer Berlin Heidelberg</general><general>Springer Nature B.V</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7RV</scope><scope>7TK</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8C1</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9-</scope><scope>K9.</scope><scope>KB0</scope><scope>M0R</scope><scope>M0S</scope><scope>M1P</scope><scope>NAPCQ</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-2813-4487</orcidid></search><sort><creationdate>20190201</creationdate><title>Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns</title><author>Palmero, David ; Di Paolo, Ermindo R. ; Stadelmann, Corinne ; Pannatier, André ; Sadeghipour, Farshid ; Tolsa, Jean-François</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c372t-6cd4f64d6f5f05186f2be1afe6a9d9137e3eceac966dad3d681712e3e38c13e3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Attention</topic><topic>Caregivers</topic><topic>Gestational age</topic><topic>Hospitalization - statistics & numerical data</topic><topic>Hospitals</topic><topic>Human error</topic><topic>Humans</topic><topic>Infant, Newborn</topic><topic>Intensive Care Units, Neonatal - standards</topic><topic>Intensive Care Units, Neonatal - statistics & numerical data</topic><topic>Medical errors</topic><topic>Medication Errors - statistics & numerical data</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Neonates</topic><topic>Newborn babies</topic><topic>Original Article</topic><topic>Pediatrics</topic><topic>Pharmacists</topic><topic>Quality control</topic><topic>Risk Factors</topic><topic>Risk Management - methods</topic><topic>Switzerland</topic><topic>Watchful Waiting - methods</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Palmero, David</creatorcontrib><creatorcontrib>Di Paolo, Ermindo R.</creatorcontrib><creatorcontrib>Stadelmann, Corinne</creatorcontrib><creatorcontrib>Pannatier, André</creatorcontrib><creatorcontrib>Sadeghipour, Farshid</creatorcontrib><creatorcontrib>Tolsa, Jean-François</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Neurosciences Abstracts</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Public Health Database</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 Central</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>Consumer Health Database</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Consumer Health Database</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Nursing & Allied Health Premium</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 China</collection><collection>MEDLINE - Academic</collection><jtitle>European journal of pediatrics</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Palmero, David</au><au>Di Paolo, Ermindo R.</au><au>Stadelmann, Corinne</au><au>Pannatier, André</au><au>Sadeghipour, Farshid</au><au>Tolsa, Jean-François</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns</atitle><jtitle>European journal of pediatrics</jtitle><stitle>Eur J Pediatr</stitle><addtitle>Eur J Pediatr</addtitle><date>2019-02-01</date><risdate>2019</risdate><volume>178</volume><issue>2</issue><spage>259</spage><epage>266</epage><pages>259-266</pages><issn>0340-6199</issn><eissn>1432-1076</eissn><abstract>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 < 32.0 weeks (
p
= 0.04) and the number of drugs prescribed (
p
< 0.01).
Conclusion
: Caregivers underreported the true rate of medication errors. Most medication errors were caused by inattention and could have been limited by simplifying the medication process. Risk of medication errors is increased in newborns < 32.0 weeks and increases with the number of drugs prescribed to each patient.
What is Known:
•
Newborns in hospitals are particularly susceptible to medication errors.
•
Identification and understanding the reasons for medication errors should help us to establish preventive measures to reduce the occurrence of such errors.
What is New:
•
Direct observation of the medication process, though time consuming, is essential to accurately assess the frequency of medication errors, which are underreported by caregivers. Most medication errors are caused by inattention and could be limited by simplifying the medication process.
•
The risk of medication errors was significantly increased in very preterm newborns (< 32 weeks) and when the number of prescription per patient increased.</abstract><cop>Berlin/Heidelberg</cop><pub>Springer Berlin Heidelberg</pub><pmid>30460407</pmid><doi>10.1007/s00431-018-3294-8</doi><tpages>8</tpages><orcidid>https://orcid.org/0000-0002-2813-4487</orcidid></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0340-6199 |
| ispartof | European journal of pediatrics, 2019-02, Vol.178 (2), p.259-266 |
| issn | 0340-6199 1432-1076 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_2136550698 |
| source | Springer Nature |
| 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 |
| title | Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns |
| url | http://sfxeu10.hosted.exlibrisgroup.com/loughborough?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-19T23%3A10%3A24IST&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=Incident%20reports%20versus%20direct%20observation%20to%20identify%20medication%20errors%20and%20risk%20factors%20in%20hospitalised%20newborns&rft.jtitle=European%20journal%20of%20pediatrics&rft.au=Palmero,%20David&rft.date=2019-02-01&rft.volume=178&rft.issue=2&rft.spage=259&rft.epage=266&rft.pages=259-266&rft.issn=0340-6199&rft.eissn=1432-1076&rft_id=info:doi/10.1007/s00431-018-3294-8&rft_dat=%3Cproquest_cross%3E2135819172%3C/proquest_cross%3E%3Cgrp_id%3Ecdi_FETCH-LOGICAL-c372t-6cd4f64d6f5f05186f2be1afe6a9d9137e3eceac966dad3d681712e3e38c13e3%3C/grp_id%3E%3Coa%3E%3C/oa%3E%3Curl%3E%3C/url%3E&rft_id=info:oai/&rft_pqid=2135819172&rft_id=info:pmid/30460407&rfr_iscdi=true |