Pediatric Drugs · 2021 · 18 citations · 22 references
Health ProfessionsChild HealthPediatricsNeonatologyPatient SafetyPediatric EpidemiologyAdverse Drug Event ReportingMedication Error ReportingMedication SafetyNeonatal Intensive CareNeonatal SafetyPediatric Patient SafetyHealthcare Incident ReportsInfant Medication SafetyInpatient Pediatric Medication SafetyIntensive Care UseMedication Safety Incident ReportingMixed Methods AnalysisPatient Safety IncidentsPediatric Adverse Drug Event Reporting
BACKGROUND: Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas. OBJECTIVE: This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs). METHODS: We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents. RESULTS: In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols. CONCLUSIONS: Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.
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Medication Errors and Adverse Drug Events in Pediatric Inpatients
Rainu Kaushal · JAMA · 2001 · 1.9K citations
Effects of increasing nurse staffing on missed nursing care
Seok Hyun Cho, Yong-Soo Kim, K.N. Yeon et al. · International Nursing Review · 2015 · 160 citations