Medication Errors in Children

Ian Chi Kei Wong Head and Professor

Centre for Safe Medication Practice and Research Department of Pharmacology and Pharmacy

University of Hong Kong

Global Research in Paediatrics – Network of Excellence (GRiP)

“A cheerful heart is good medicine, but a crushed spirit dries up the bones. (Proverbs 17:22)”.

Learning outcomes

• At the end of the session, you will be able to: – Explain why children are at greater risk of

medication errors. – Describe epidemiology and nature of medication

error in children. – Five risks

Literature review

Literature review

• Great variation in the paediatric medication error rates reported due to differences in study design. – prescribing error rate 0.45 to 30.1 errors per 100

orders in the USA – drug administration error rates varied from 0.6% to

27%

• Dosing errors are the most common type of errors in paediatrics (particularly 10-fold or greater overdose caused by calculation errors).

How big is the problem in our hospital?

Why children may be at greater risk from medication errors

• Drug doses are calculated based on a patient’s age, weight or body surface area.

• Weight changes over time & recalculation of drug doses is required, particularly in neonates.

• Inadequate information. • Inadequate availability of appropriate dosage

forms and concentrations. • Fewer internal reserves to buffer any

medication errors which may occur.

Medication errors can occur at various stages

1 Prescribing 2 Transcribing 3 Dispensing 4 Administration

Medication errors can occur at various stages

1 Prescribing 2 Transcribing 3 Dispensing 4 Administration

Medication errors can occur at various stages

1 Prescribing 2 Transcribing 3 Dispensing 4 Administration

Pharmacist Prepared Wrong strength of Peppermint water 20 times overdose

Medication errors can occur at various stages

1 Prescribing 2 Transcribing 3 Dispensing 4 Administration

Nurse injected 10 times more digoxin to a baby

Be aware

• Mistakes can happen at any stage. • Everyone in the healthcare team can make a

mistake. • Including you!

When you make a mistake, admit it, correct it, and learn from it -

immediately.

Stephen Covey

Summary of High Risk 1) High risk paediatric groups

Neonatal, learning difficulty and oncology 2) High risk drug groups

Analgesics, anticonvulsants, any high potent drugs 3) High risk pharmaceutical formulations

Adult formulations for paediatric use, IV, Unlicensed products

4) High risk healthcare workers Unqualified, Inexperienced, Newly appointed and Tired

5) High risk changing care settings Admission and discharge

Is it you?

GRiP www.grip-network.org

• The “Global Research in Paediatrics – Network of Excellence (GRiP)” is an EU-funded project.

• GRiP aims to implement an infrastructure matrix to stimulate & facilitate the development & safe use of pediatric medicines.

References • Conroy S, Yeung V, Sweis D, Collier J, Haines L, Wong ICK.

Systematic literature review of interventions to reduce dosing errors in children. Drug Safety 2007;30(12):1111-25.

• Ghaleb M, Barber N, Franklin B, Wong ICK. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child 2010;95(2):113-8.

• Ghaleb MA, Dean Franklin B, Barber N, Khaki Z, Yeung Y, Wong ICK. A Systematic Review of Medication Errors in Pediatric Patients. Annals of Pharmacotherapy 2006 40(10):1766-76.

• Wong IC, Wong LY, Cranswick NE. Minimising medication errors in children. Arch Dis Child 2009;94(2):161-4.