Inpatient paediatric medication errors - what can be learned from enquiries made to the National Poisons Information Service (Cardiff Unit)?

Tharian, Kavitha, Thompson, John Paul and Tuthill, David 2010. Inpatient paediatric medication errors - what can be learned from enquiries made to the National Poisons Information Service (Cardiff Unit)? Welsh Paediatric Journal 34 , pp. 19-21.

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Abstract

Introduction Medication errors are one of the more common types of medical error. Much of the research into medication errors and their prevention has been carried out in the adult population. Fewer data exist on medication errors in paediatrics. Children may be more affected than adults by adverse medication events because of their lower body weight, altered pharmacology and their dependency on adult carers. The National Patient Safety Agency (NPSA) strongly advocates an open reporting culture. Review of reported errors can generate learning points enabling improvements in patient safety. We wished to explore the incidence, nature and severity of reported adverse medication events occurring in paediatric hospital settings which resulted in telephone enquiries to the National Poisons Information Service (Cardiff Unit). Aim To identify and analyse in-hospital paediatric medication errors which resulted in advice being sought from the National Poisons Information Service (Cardiff Unit). Methods Information concerning enquiries to the National Poisons Information Service (NPIS) is recorded in a structured fashion using the United Kingdom Poisons Information Database (UKPID). This database was interrogated for enquiries to the Cardiff Unit over a 3½ year period between 2004 and 2007 to ascertain those medication errors occurring in hospital for children aged 16 years or less. Results There were 82 enquiries involving suspected childhood medication errors occurring in hospital during this period. These included 16 children aged <1month, 36 aged 1month to 5 years, 19 aged 6 to 11 years and 11 children aged 12 to 16 years. Calls were received from throughout the British Isles. The routes of drug delivery involved included oral (n=46), intravenous (n=30), intramuscular (n=3) and intrathecal or epidural (n=3). Follow-up data were not available for all enquiries; however 59 cases needed specific treatment or a prolonged inpatient stay. There were no reported deaths. Conclusion Most enquiries to NPIS (Cardiff Unit) concerning suspected in-patient childhood medication errors involved children under the age of five years and were associated with a prolonged hospital stay. Poisons information data may be used as a source of information about medication errors and their consequences. A culture of open reporting of medication errors should be encouraged so that lessons can be learnt and safer systems for administering medicines developed.

Item Type:	Article
Date Type:	Publication
Status:	Published
Schools:	Medicine
Subjects:	R Medicine > RJ Pediatrics > RJ101 Child Health. Child health services
Publisher:	Welsh Paediatric Society
Last Modified:	06 Feb 2022 11:39
URI:	https://orca.cardiff.ac.uk/id/eprint/29926

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