Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, J. B. Winsløws Vej 19.2, 5000, Odense, Denmark.
Section of Social and Clinical Pharmacy, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark.
Eur J Pediatr. 2017 Dec;176(12):1697-1705. doi: 10.1007/s00431-017-3023-8. Epub 2017 Oct 1.
The aim was to describe medication errors (MEs) in hospitalized children reported to the national mandatory reporting and learning system, the Danish Patient Safety Database (DPSD). MEs were extracted from DPSD from the 5-year period of 2010-2014. We included reports from public hospitals on patients aged 0-17 years and categorized by reporters as medication-related. Reports from psychiatric wards and outpatient clinics were excluded. A ME was defined as any medication-related error occurring in the medication process whether harmful or not. MEs were categorized as harmful if they resulted in actual harm or interventions to prevent harm. MEs were further categorized according to occurrence in the medication process, type of error, and the medicines involved. A total of 2071 MEs including 487 harmful MEs were identified. Most MEs occurred during prescribing (40.8%), followed by dispensing (38.7%). Harmful MEs occurred mainly during dispensing (40.3%). Dosing errors were the most reported type of error, 47.7% of all MEs and 45.4% of harmful MEs. Antibiotics and analgesics were the most frequently reported medication classes. Common medicines associated with MEs included morphine, paracetamol, and gentamicin. MEs caused no harm (74.9%), mild (11.7%), moderate (10.5%), or severe harm (1.3%), but none were lethal.
MEs in hospitalized children occur in all medication processes and mainly involve dosing errors. Strategies should be developed to prevent MEs as these still threaten medication safety in pediatric inpatients. What is known: • Hospitalized children are more likely to experience medication errors than adults. • Voluntary national and local reporting and learning systems have previously been used to describe the nature and types of medication errors. What is new: • Medication errors in hospitalized children occur in all steps of the medication process, most frequently involving dosing errors and most commonly involving morphine, paracetamol, and gentamicin. • Of the medication errors, 1.3% cause severe harm, but no fatal errors were reported.
目的是描述向丹麦国家强制性报告和学习系统（DPSD）报告的住院儿童用药错误（MEs）。从 2010-2014 年的 5 年期间，从 DPSD 中提取 MEs。我们纳入了来自公立医院的 0-17 岁患者报告，并根据报告人将其归类为与药物相关。精神科病房和门诊报告被排除在外。ME 被定义为药物治疗过程中发生的任何药物相关错误，无论是否有害。如果导致实际伤害或干预以防止伤害，则将 MEs 归类为有害。根据药物治疗过程中的发生情况、错误类型和涉及的药物对 MEs 进行进一步分类。确定了 2071 例 MEs，包括 487 例有害 MEs。大多数 MEs 发生在处方（40.8%）期间，其次是配药（38.7%）。有害 MEs 主要发生在配药期间（40.3%）。剂量错误是报告最多的错误类型，占所有 MEs 的 47.7%，有害 MEs 的 45.4%。抗生素和镇痛药是最常报告的药物类别。与 MEs 相关的常见药物包括吗啡、对乙酰氨基酚和庆大霉素。MEs 未造成伤害（74.9%）、轻度伤害（11.7%）、中度伤害（10.5%）或严重伤害（1.3%），但均无致命伤害。
住院儿童的 MEs 发生在所有药物治疗过程中，主要涉及剂量错误。应制定策略以预防 MEs，因为这些错误仍会威胁儿科住院患者的药物安全。已知内容：•住院儿童比成年人更容易发生用药错误。•以前曾使用国家和地方自愿报告和学习系统来描述用药错误的性质和类型。新内容：•住院儿童的用药错误发生在药物治疗过程的所有步骤中，最常涉及剂量错误，最常见的涉及吗啡、对乙酰氨基酚和庆大霉素。•在这些用药错误中，1.3%造成严重伤害，但没有报告致命错误。
