Centre for Medical Education, Queen's University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, UK.
Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK.
Paediatr Drugs. 2020 Oct;22(5):551-560. doi: 10.1007/s40272-020-00407-1.
To protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data could provide this but are often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates.
Our aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients.
We conducted a retrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. The following characteristics were included: error severity, patient age, drug involved, error type, and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analyzed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups.
Neonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%).
Incident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviors, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community in their future implementation. The utility of incident reports to direct improvement efforts may offset the limitations in their representativeness.
为了保护儿童免受伤害，临床医生、教育工作者和患者安全拥护者需要信息来指导改进工作。关键事件数据可以提供这些信息，但由于报告不足，它们通常被视为证据来源不准确，因为错误率无法准确衡量。
我们旨在确定儿科医疗保健质量改进的关键目标。目的是评估报告的儿科患者用药错误中的类型、特征和风险领域。
我们对 2011 年至 2015 年期间来自北爱尔兰二级保健的 1522 例儿科用药错误的大型区域数据集进行了回顾性研究，包括所有医院和社区儿科环境。包括以下特征：错误严重程度、患者年龄、涉及的药物、错误类型和实践领域。两位儿科医生、一位高级药物治理药剂师、一位药学实践研究员和一位医学教育教授分析了这些数据。有效性检查包括将研究结果与关键已发表文献进行比较，并由代表五个多学科利益相关者群体的从业者小组进行讨论。
新生儿，特别是在重症监护病房，占所有错误的 19%。风险最大的药物是抗生素、对乙酰氨基酚、疫苗和静脉输液。最常见的错误类型是剂量错误（32%）和遗漏（21%）。
事件报告确定了与可改变行为相关的新生儿、一组药物和特定错误类型作为优先改进目标。这些发现指导进一步的研究，并为干预措施的发展提供信息，例如预防剂量错误的特定计算培训。经验丰富的从业者的参与不仅认可了这些发现，还使实践社区参与了它们的未来实施。事件报告指导改进工作的效用可能会弥补其代表性的局限性。
