SLIDE 1 Medication Errors in Children
Ian Chi Kei Wong
Head and Professor Centre for Safe Medication Practice and Research Department of Pharmacology and Pharmacy University of Hong Kong Global Research in Paediatrics – Network of Excellence (GRiP)
“A cheerful heart is good medicine, but a crushed spirit dries up the bones. (Proverbs 17:22)”.
SLIDE 2 Learning outcomes
- At the end of the session, you will be able to:
– Explain why children are at greater risk of medication errors. – Describe epidemiology and nature of medication error in children. – Five risks
SLIDE 3
Literature review
SLIDE 4 Literature review
- Great variation in the paediatric medication error
rates reported due to differences in study design.
– prescribing error rate 0.45 to 30.1 errors per 100
– drug administration error rates varied from 0.6% to 27%
- Dosing errors are the most common type of
errors in paediatrics (particularly 10-fold or greater overdose caused by calculation errors).
SLIDE 5
How big is the problem in our hospital?
SLIDE 6
SLIDE 7
SLIDE 8 Why children may be at greater risk from medication errors
- Drug doses are calculated based on a
patient’s age, weight or body surface area.
- Weight changes over time & recalculation of
drug doses is required, particularly in neonates.
- Inadequate information.
- Inadequate availability of appropriate dosage
forms and concentrations.
- Fewer internal reserves to buffer any
medication errors which may occur.
SLIDE 9
Medication errors can occur at various stages
1 Prescribing 2 Transcribing 3 Dispensing 4 Administration
SLIDE 10
SLIDE 11
Medication errors can occur at various stages
1 Prescribing 2 Transcribing 3 Dispensing 4 Administration
SLIDE 12
SLIDE 13
Medication errors can occur at various stages
1 Prescribing 2 Transcribing 3 Dispensing 4 Administration
SLIDE 14
Pharmacist Prepared Wrong strength of Peppermint water 20 times overdose
SLIDE 15
Medication errors can occur at various stages
1 Prescribing 2 Transcribing 3 Dispensing 4 Administration
SLIDE 16
Nurse injected 10 times more digoxin to a baby
SLIDE 17 Be aware
- Mistakes can happen at any stage.
- Everyone in the healthcare team can make a
mistake.
SLIDE 18
When you make a mistake, admit it, correct it, and learn from it - immediately.
Stephen Covey
SLIDE 19
Summary of High Risk
1) High risk paediatric groups
Neonatal, learning difficulty and oncology
2) High risk drug groups
Analgesics, anticonvulsants, any high potent drugs
3) High risk pharmaceutical formulations
Adult formulations for paediatric use, IV, Unlicensed products
4) High risk healthcare workers
Unqualified, Inexperienced, Newly appointed and Tired
5) High risk changing care settings
Admission and discharge
SLIDE 20
Is it you?
SLIDE 21 GRiP www.grip-network.org
- The “Global Research in Paediatrics – Network
- f Excellence (GRiP)” is an EU-funded project.
- GRiP aims to implement an infrastructure
matrix to stimulate & facilitate the development & safe use
pediatric medicines.
SLIDE 22 References
- Conroy S, Yeung V, Sweis D, Collier J, Haines L, Wong ICK.
Systematic literature review of interventions to reduce dosing errors in children. Drug Safety 2007;30(12):1111-25.
- Ghaleb M, Barber N, Franklin B, Wong ICK. The incidence
and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child 2010;95(2):113-8.
- Ghaleb MA, Dean Franklin B, Barber N, Khaki Z, Yeung Y,
Wong ICK. A Systematic Review of Medication Errors in Pediatric Patients. Annals of Pharmacotherapy 2006 40(10):1766-76.
- Wong IC, Wong LY, Cranswick NE. Minimising medication
errors in children. Arch Dis Child 2009;94(2):161-4.
