Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
Pediatrics. 2012 May;129(5):916-24. doi: 10.1542/peds.2011-2526. Epub 2012 Apr 2.
Tenfold medication errors are a significant source of risk to pediatric patients. This may be because of wide variations in age, weight, dosing ranges, and off-label practices, but few studies exclusively devoted to examining pediatric 10-fold error have identified the circumstances and mechanisms that lead to such errors. We examined all 10-fold medication errors reported within an academic, university-affiliated pediatric hospital to make recommendations for future initiatives that could improve medication safety in pediatric practice.
We retrospectively evaluated all medication-related incident reports submitted to a voluntary safety-reporting database over a 5-year period for reports describing 10-fold medication error. Main outcome measures comprised severity of error, drugs and drug classes involved, 10-fold medication error enablers, mechanisms, and contributing causes.
From 6643 medication-related safety reports, 252 10-fold medication errors were identified at a mean reporting rate of 0.062 per 100 total patient days. Morphine was the most frequently reported medication, and opioids were the most frequently reported drug class. Twenty-two reports described patient harm. Intravenous formulations, paper ordering, and drug-delivery pumps were frequent error enablers. Errors of dose calculation, documentation of decimal points, and confusion with zeroes were frequent contributing causes to 10-fold medication error.
This study exclusively and comprehensively examined 10-fold medication errors over a prolonged time in pediatric inpatients. We discuss recommendations of vigilance for specific drugs and standardized order sets for opioids and antibiotics, and identify the administering phase of the medication process as a high-risk practice that can result in pediatric 10-fold medication error.
十倍用药错误是儿科患者的一个重大风险源。这可能是由于年龄、体重、剂量范围和超说明书用药的广泛差异所致，但很少有专门研究儿科十倍用药错误的研究确定了导致此类错误的情况和机制。我们检查了在学术型大学附属儿科医院内报告的所有十倍用药错误，以提出未来可提高儿科实践中用药安全性的倡议建议。
我们回顾性评估了在五年期间向自愿安全报告数据库提交的所有与用药相关的事件报告中，描述十倍用药错误的报告。主要结局指标包括错误的严重程度、涉及的药物和药物类别、十倍用药错误的促成因素、机制和促成原因。
从 6643 份与用药相关的安全报告中，确定了 252 例十倍用药错误，平均报告率为每 100 名患者住院日 0.062 例。吗啡是报告最多的药物，阿片类药物是报告最多的药物类别。有 22 份报告描述了患者伤害。静脉制剂、纸质医嘱和药物输送泵是常见的错误促成因素。剂量计算错误、小数点记录错误和零混淆是导致十倍用药错误的常见促成原因。
这项研究专门且全面地在儿科住院患者中长时间检查了十倍用药错误。我们讨论了针对特定药物的警惕性建议和阿片类药物和抗生素的标准化医嘱集建议，并确定了药物使用过程的给药阶段是导致儿科十倍用药错误的高风险实践。
