Advertisement

European Journal of Pediatrics

, Volume 178, Issue 2, pp 259–266 | Cite as

Incident reports versus direct observation to identify medication errors and risk factors in hospitalised newborns

  • David PalmeroEmail author
  • Ermindo R. Di Paolo
  • Corinne Stadelmann
  • André Pannatier
  • Farshid Sadeghipour
  • Jean-François Tolsa
Original Article

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.

Keywords

Medication errors Newborn Risk factors Neonatal intensive care unit Patient safety Quality improvement 

Abbreviations

NICU

Neonatal intensive care unit

Notes

Acknowledgements

We give special thanks to Dr. Jérôme Pasquier for his statistical analysis.

Authors’ contribution

D. Palmero, E.R. Di Paolo, A. Pannatier, F. Sadeghipour and J.-F. Tolsa designed the study. D. Palmero made the observations and collected the data. D. Palmero, E.R. Di Paolo and C. Stadelmann analyzed the data. D. Palmero wrote the manuscript. All authors contributed to and approved the final version of the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The Ethics Committee for Human Research of Canton Vaud approved the study protocol before the enrolment of the first patient.

Animal studies

This article does not contain any studies with animal performed by any of the authors.

References

  1. 1.
    Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L (1995) Relationship between medication errors and adverse drug events. J Gen Intern Med 10:199–205CrossRefGoogle Scholar
  2. 2.
    Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324:370–376CrossRefGoogle Scholar
  3. 3.
    Brown G (1979) Medication errors: a case study. Hospitals 53(61–62):65Google Scholar
  4. 4.
    Campino A, Arranz C, Unceta M, Rueda M, Sordo B, Pascual P, Lopez-de-Heredia I, Santesteban E (2016) Medicine preparation errors in ten Spanish neonatal intensive care units. Eur J Pediatr 175:203–210CrossRefGoogle Scholar
  5. 5.
    Campino A, Lopez-Herrera MC, Lopez-de-Heredia I, Valls-i-Soler A (2009) Educational strategy to reduce medication errors in a neonatal intensive care unit. Acta Paediatr 98:782–785CrossRefGoogle Scholar
  6. 6.
    Cloherty JP, Eichenwald ER, Stark AR (2010) Manual of neonatal care, 6th edn. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  7. 7.
    Cohen MR (2007) Medication errors, 2nd edn. The American Pharmacist Association, Washington, DCCrossRefGoogle Scholar
  8. 8.
    Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL (1995) The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 21:541–548Google Scholar
  9. 9.
    Eslami S, Abu-Hanna A, de Keizer NF, de Jonge E (2006) Errors associated with applying decision support by suggesting default doses for aminoglycosides. Drug Saf 29:803–809CrossRefGoogle Scholar
  10. 10.
    Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL (2002) Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 59:436–446Google Scholar
  11. 11.
    Frey B, Kehrer B, Losa M, Braun H, Berweger L, Micallef J, Ebenberger M (2000) Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach. Intensive Care Med 26:69–74CrossRefGoogle Scholar
  12. 12.
    Glanzmann C, Frey B, Meier CR, Vonbach P (2015) Analysis of medication prescribing errors in critically ill children. Eur J Pediatr 174:1347–1355CrossRefGoogle Scholar
  13. 13.
    Jha AK, Kuperman GJ, Teich JM, Leape L, Shea B, Rittenberg E, Burdick E, Seger DL, Vander Vliet M, Bates DW (1998) Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 5:305–314CrossRefGoogle Scholar
  14. 14.
    Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA (2001) Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120CrossRefGoogle Scholar
  15. 15.
    Kugelman A, Inbar-Sanado E, Shinwell ES, Makhoul IR, Leshem M, Zangen S, Wattenberg O, Kaplan T, Riskin A, Bader D (2008) Iatrogenesis in neonatal intensive care units: observational and interventional, prospective, multicenter study. Pediatrics 122:550–555CrossRefGoogle Scholar
  16. 16.
    Larsen GY, Parker HB, Cash J, O'Connell M, Grant MC (2005) Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics 116:e21–e25CrossRefGoogle Scholar
  17. 17.
    Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324:377–384CrossRefGoogle Scholar
  18. 18.
    Ligi I, Arnaud F, Jouve E, Tardieu S, Sambuc R, Simeoni U (2008) Iatrogenic events in admitted neonates: a prospective cohort study. Lancet 371:404–410CrossRefGoogle Scholar
  19. 19.
    Ligi I, Millet V, Sartor C, Jouve E, Tardieu S, Sambuc R, Simeoni U (2010) Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. Pediatrics 126:e1461–e1468CrossRefGoogle Scholar
  20. 20.
    Manrique-Rodriguez S, Sanchez-Galindo AC, Lopez-Herce J, Calleja-Hernandez MA, Martinez-Martinez F, Iglesias-Peinado I, Carrillo-Alvarez A, Sanjurjo Saez M, Fernandez-Llamazares CM (2013) Impact of implementing smart infusion pumps in a pediatric intensive care unit. Am J Health Syst Pharm 70:1897–1906CrossRefGoogle Scholar
  21. 21.
    Meyer-Massetti C, Cheng CM, Schwappach DL, Paulsen L, Ide B, Meier CR, Guglielmo BJ (2011) Systematic review of medication safety assessment methods. Am J Health Syst Pharm 68:227–240CrossRefGoogle Scholar
  22. 22.
    Montesi G, Lechi A (2009) Prevention of medication errors: detection and audit. Br J Clin Pharmacol 67:651–655CrossRefGoogle Scholar
  23. 23.
    National Coordinating Council for Medication Error Reporting and Prevention (2012) NCC MERP taxonomy of medication errors. http://www.nccmerp.org/sites/default/files/taxonomy2001-07-31.pdf. Accessed 10 Dec 2012
  24. 24.
    Palmero D, Di Paolo ER, Beauport L, Pannatier A, Tolsa JF (2016) A bundle with a preformatted medical order sheet and an introductory course to reduce prescription errors in neonates. Eur J Pediatr 175:113–119CrossRefGoogle Scholar
  25. 25.
    Shannon RC, DeMuth JE (1987) Comparison of medication-error detection methods in the long term care facilities. Consult Pharm 2(Mar-Apr):148–151Google Scholar
  26. 26.
    Snijders C, van Lingen RA, Klip H, Fetter WP, van der Schaaf TW, Molendijk HA, NEOSAFE study group (2009) Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. Arch Dis Child Fetal Neonatal Ed 94:F210–F215CrossRefGoogle Scholar
  27. 27.
    Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR (2010) NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. J Perinatol 30:459–468CrossRefGoogle Scholar
  28. 28.
    Suresh G, Horbar JD, Plsek P, Gray J, Edwards WH, Shiono PH, Ursprung R, Nickerson J, Lucey JF, Goldmann D (2004) Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 113:1609–1618CrossRefGoogle Scholar
  29. 29.
    Taylor JA, Loan LA, Kamara J, Blackburn S, Whitney D (2008) Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. Pediatrics 121:123–128CrossRefGoogle Scholar
  30. 30.
    Wilson DG, McArtney RG, Newcombe RG, McArtney RJ, Gracie J, Kirk CR, Stuart AG (1998) Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr 157:769–774CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PharmacyLausanne University HospitalLausanneSwitzerland
  2. 2.School of Pharmaceutical SciencesGeneva and Lausanne UniversitiesGenevaSwitzerland
  3. 3.Clinic of NeonatologyLausanne University HospitalLausanneSwitzerland

Personalised recommendations