Results of a program to prevent medication errors in a pediatric emergency department

Vilà De Muga M, Messegué Medà M, Astete J, Luaces Cubells C

Background and objective: Drug prescription errors are a significant cause of

preventable morbidity and mortality in children. Our aim was to assess whether the

frequency of medication error decreased after a prevention program was implemented

in a pediatric emergency department.

Material and methods: Observational pre- and postintervention study. We identified

errors made in November 2009 (preintervention period) by reviewing patient records.

Errors were classified by type (dose, indication, route of administration), level of

seriousness (low, moderate, high), and associated factors (staff experience, seriousness of

the emergency, day of the week, hour of the day). In 2010 sessions to provide

information about the detected errors were held and informative posters were hung in

the department. Errors were again identified in November 2010 (postintervention

period) and the results were compared.

Results: Errors were made most often with bronchodilators, corticosteroids, and antiinflammatory

drugs. In the first period, out of 445 prescriptions made, 49 errors (11%)

were detected; in the second period, 48 errors in 557 prescriptions (8.6%) were

detected. The difference was not significant. The rate of dosage error decreased

significantly between the 2 periods (7.4% vs 3.8%, P=.016), but we saw no significant

changes in incorrect indication, choice of route of administration, or seriousness. During

the postintervention period, fewer errors were made in the most serious emergencies

(11.6% vs 5.7%; P=.005) and between midnight and 8 a.m. (16.2% vs 6.1%; P=.02).

Conclusions: The error prevention program allowed us to reduce some types of

medication error but follow-up and continued insistence on vigilance is required.

Astete J, Luaces Cubells C, Messegué Medà M, Vilà De Muga M