Medication Errors in Pediatrics: Proposals to Improve the Quality and Safety of Care Through Clinical Risk Management

Medication errors represent one of the most common causes of adverse events in pediatrics and are widely reported in the literature. Despite the awareness that children are at increased risk for medication errors, little is known about the real incidence of the phenomenon. Most studies have focused on prescription, although medication errors also include transcription, dispensing, dosage, administration, and certification errors. Known risk factors for therapeutic errors include parenteral infusions, oral fluid administration, and tablet splitting, as well as the off-label use of drugs with dosages taken from adult literature. Emergency Departments and Intensive Care Units constitute the care areas mainly affected by the phenomenon in the hospital setting. The present paper aims to identify the risk profiles in pediatric therapy to outline adequate preventive strategies. Precisely, through the analysis of the available evidence, solutions such as standardization of recommended doses for children, electronic prescribing, targeted training of healthcare professionals, and implementation of reporting systems will be indicated for the prevention of medication errors.

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Interventions to reduce medication errors in neonatal care: a systematic review

Therapeutic Advances in Drug Safety ◽

10.1177/2042098617748868 ◽

2017 ◽

Vol 9 (2) ◽

pp. 123-155 ◽

Cited By ~ 18

Author(s):

Minh-Nha Rhylie Nguyen ◽

Cassandra Mosel ◽

Luke E. Grzeskowiak

Keyword(s):

Systematic Review ◽

Medication Errors ◽

Error Detection ◽

Medication Safety ◽

Hospital Setting ◽

Electronic Prescribing ◽

Clinical Pharmacy Service ◽

Reference List ◽

Safety Interventions ◽

The Impact

Background: Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. Methods: A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. Results: A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology ( n = 38; e.g. electronic prescribing), organizational ( n = 16; e.g. guidelines, policies, and procedures), personnel ( n = 13; e.g. staff education), pharmacy ( n = 9; e.g. clinical pharmacy service), hazard and risk analysis ( n = 8; e.g. error detection tools), and multifactorial ( n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50–70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. Conclusion: While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice.

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Prehospital Diagnosis of Shortness of Breath Caused by Profound Metformin-Associated Metabolic Acidosis

Healthcare ◽

10.3390/healthcare9010074 ◽

2021 ◽

Vol 9 (1) ◽

pp. 74

Author(s):

Pietro Elias Fubini ◽

Laurent Suppan

Keyword(s):

Metabolic Acidosis ◽

Hospital Setting ◽

Blood Gases ◽

Shortness Of Breath ◽

Potential Harm ◽

Arterial Blood Gas ◽

Arterial Blood ◽

Common Causes ◽

Prehospital Diagnosis ◽

Gas Measurement

Shortness of breath is a common complaint among patients in emergency medicine. While most common causes are usually promptly identified, less frequent aetiologies might be challenging to diagnose, especially in the pre-hospital setting. We report a case of prehospital dyspnoea initially ascribed to pulmonary oedema which turned out to be the result of profound metformin-associated metabolic acidosis. This diagnosis was already made during the prehospital phase by virtue of arterial blood gas measurement. Pre-hospital measurement of arterial blood gases is therefore feasible and can improve diagnostic accuracy in the field, thus avoiding unnecessary delay and potential harm to the patient before initiating the appropriate therapeutic actions.

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62 A Retrospective Observational Study Into the Correct Administration of Rivaroxaban: Is it Being Taken with Food?

Age and Ageing ◽

10.1093/ageing/afab030.23 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

pp. i12-i42

Author(s):

E Spurring ◽

G Donnelly

Keyword(s):

Drug Safety ◽

Healthcare Professionals ◽

Hospital Environment ◽

Electronic Prescribing ◽

Academic Knowledge ◽

Increased Risk ◽

Swallowing Difficulties ◽

The Difference ◽

Medical Wards ◽

Hospitalised Patient

Abstract Intro In July 2019 the MHRA issued a drug safety update reminding healthcare professionals that rivaroxaban should be taken with food. This came after they received a number of thromboembolic events reported in patients prescribed rivaroxaban, thought to be linked with incorrect ingestion on an empty stomach [1]. Our aim was to establish if the healthcare professionals in our department had this knowledge and to audit our current dispensing practice to assess if our hospitalised patient cohort were being exposed to any increased risk. Methods A retrospective study was conducted using electronic data from 21 patients that were prescribed rivaroxaban across 14 medical wards. A questionnaire was used to establish the staff’s knowledge. Results Of the surveyed healthcare professionals, 79% knew that rivaroxaban should be taken with food (86% of nurses and 79% of doctors). Despite this only 17% of patients took the tablet with food. 75% of patients had rivaroxaban incorrectly dispensed over an hour post meal and 8% were uncertain due to poor documentation. Only 14% of healthcare professionals were aware that in those with swallowing difficulties, rivaroxaban can be crushed. Conclusions In our department most of the healthcare professionals had a good academic knowledge of correct rivaroxaban administration, however we have demonstrated that this is failing to correctly influence clinical practice. 75% of patients taking Rivaroxaban in hospital are being subjected to increased risk due to the hospital environment. This was found to relate to the difference in timing of the drug dispensing round in comparison to meal times. As part of the roll out of electronic prescribing in our trust, a warning now shows when both prescribing and dispensing Rivaroxaban to attempt to improve this highlighted risk. We have also highlighted this to the ward managers and at our governance meeting. Reference 1. Drug Safety Update volume 12, issue 12: July 2019: 3.

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Focal segmental glomerulosclerosis is associated with a PDSS2 haplotype and, independently, with a decreased content of coenzyme Q10

AJP Renal Physiology ◽

10.1152/ajprenal.00143.2013 ◽

2013 ◽

Vol 305 (8) ◽

pp. F1228-F1238 ◽

Cited By ~ 24

Author(s):

David L. Gasser ◽

Cheryl A. Winkler ◽

Min Peng ◽

Ping An ◽

Louise M. McKenzie ◽

...

Keyword(s):

Focal Segmental Glomerulosclerosis ◽

Cell Lines ◽

Coenzyme Q ◽

Lymphoblastoid Cell Lines ◽

Nucleotide Polymorphisms ◽

Single Nucleotide ◽

Collapsing Glomerulopathy ◽

Segmental Glomerulosclerosis ◽

Increased Risk ◽

Common Causes

Focal segmental glomerulosclerosis (FSGS) and collapsing glomerulopathy are common causes of nephrotic syndrome. Variants in >20 genes, including genes critical for mitochondrial function, have been associated with these podocyte diseases. One such gene, PDSS2, is required for synthesis of the decaprenyl tail of coenzyme Q10 (Q10) in humans. The mouse gene Pdss2 is mutated in the kd/kd mouse model of collapsing glomerulopathy. We examined the hypothesis that human PDSS2 polymorphisms are associated with podocyte diseases. We genotyped 377 patients with primary FSGS or collapsing glomerulopathy, together with 900 controls, for 9 single-nucleotide polymorphisms in the PDSS2 gene in a case-control study. Subjects included 247 African American (AA) and 130 European American (EA) patients and 641 AA and 259 EA controls. Among EAs, a pair of proxy SNPs was significantly associated with podocyte disease, and patients homozygous for one PDSS2 haplotype had a strongly increased risk for podocyte disease. By contrast, the distribution of PDSS2 genotypes and haplotypes was similar in AA patients and controls. Thus a PDSS2 haplotype, which has a frequency of 13% in the EA control population and a homozygote frequency of 1.2%, is associated with a significantly increased risk for FSGS and collapsing glomerulopathy in EAs. Lymphoblastoid cell lines from FSGS patients had significantly less Q10 than cell lines from controls; contrary to expectation, this finding was independent of PDSS2 haplotype. These results suggest that FSGS patients have Q10 deficiency and that this deficiency is manifested in patient-derived lymphoblastoid cell lines.

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Predictors of clinical deterioration in patients with suspected COVID-19 managed in a ‘virtual hospital’ setting: a cohort study

BMJ Open ◽

10.1136/bmjopen-2020-045356 ◽

2021 ◽

Vol 11 (3) ◽

pp. e045356

Author(s):

Nick A Francis ◽

Beth Stuart ◽

Matthew Knight ◽

Rama Vancheeswaran ◽

Charles Oliver ◽

...

Keyword(s):

Mental Health ◽

Mental Health Problems ◽

Hospital Setting ◽

Health Problems ◽

Clinical Deterioration ◽

Care Services ◽

Increased Risk ◽

Remote Assessment ◽

History Of

ObjectiveIdentify predictors of clinical deterioration in a virtual hospital (VH) setting for COVID-19.DesignReal-world prospective observational study.SettingVH remote assessment service in West Hertfordshire NHS Trust, UK.ParticipantsPatients with suspected COVID-19 illness enrolled directly from the community (postaccident and emergency (A&E) or medical intake assessment) or postinpatient admission.Main outcome measureDeath or (re-)admission to inpatient hospital care during VH follow-up and for 2 weeks post-VH discharge.Results900 patients with a clinical diagnosis of COVID-19 (455 referred from A&E or medical intake and 445 postinpatient) were included in the analysis. 76 (8.4%) of these experienced clinical deterioration (15 deaths in admitted patients, 3 deaths in patients not admitted and 58 additional inpatient admissions). Predictors of clinical deterioration were increase in age (OR 1.04 (95% CI 1.02 to 1.06) per year of age), history of cancer (OR 2.87 (95% CI 1.41 to 5.82)), history of mental health problems (OR 1.76 (95% CI 1.02 to 3.04)), severely impaired renal function (OR for eGFR <30=9.09 (95% CI 2.01 to 41.09)) and having a positive SARS-CoV-2 PCR result (OR 2.0 (95% CI 1.11 to 3.60)).ConclusionsThese predictors may help direct intensity of monitoring for patients with suspected or confirmed COVID-19 who are being remotely monitored by primary or secondary care services. Further research is needed to confirm our findings and identify the reasons for increased risk of clinical deterioration associated with cancer and mental health problems.

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Reducing the use of high dose antipsychotic medication in acute adult inpatient psychiatric units

BJPsych Open ◽

10.1192/bjo.2021.893 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S341-S341

Author(s):

Shay-Anne Pantall ◽

Sarah Warwicker ◽

Lisa Brownell

Keyword(s):

Antipsychotic Medication ◽

Psychiatric Inpatient ◽

Electronic Prescribing ◽

Antipsychotic Treatment ◽

High Dose ◽

Junior Doctors ◽

List Type ◽

Increased Risk ◽

Adult Inpatient ◽

Inpatient Units

AimsTo evaluate the use of antipsychotics, and high dose antipsychotic treatment (HDAT) in psychiatric inpatient unitsBackgroundThe Royal College of Psychiatrists published a consensus statement on high dose antipsychotic medication in October 1993. Such treatment carries an increased risk of adverse effects including towards ventricular tachycardia and sudden death.MethodA retrospective case note review of all male patients on acute adult inpatient units in a psychiatric hospital in South Birmingham on a date in June 2018 (n = 45) including review of electronic patient records and prescriptions. This was compared with the results of an earlier study, with identical methods, undertaken in June 2015.Result•In both 2015 and 2018, only a minority of patients (20% and 11% respectively) were informal.•In both 2015 and 2018, the majority of inpatients had a diagnosis of schizophrenia (54% and 67%)•In both 2015 and 2018, 93% inpatients were prescribed antipsychotic medication.•In 2015, 56% patients were prescribed HDAT. This reduced in 2018 to 16%.•This reduction in use of HDAT was almost entirely due to a reduction in the prescription of PRN antipsychotic medication.•In terms of regularly prescribed antipsychotic medication, in both years, the most commonly prescribed drug was flupentixol, with a range of other second generation oral and long acting medications being prescribed, usually at doses within BNF limits.Between the two years, there was a substantial change in the prescribing of PRN antipsychotics. In 2015, 59% individuals were prescribed at least one PRN antipsychotic (27% were prescribed two). In 2018, this reduced to 40% prescribed at least one, and only 2% being prescribed 2 PRN antipsychotics. In both years, oral quetiapine was a common choice (39% patients in 2015 prescribed oral quetiapine, and 34% in 2018). In 2015, 39% patients were prescribed oral or intramuscular aripiprazole, while this reduced to 7% in 2018.ConclusionThe vast majority of psychiatric inpatients were being prescribed antipsychotic medication. Prescription of high dose antipsychotic medication was common in 2015, and this was largely attributable to high levels of prescribing of PRN antipsychotics. Following an educational programme for junior doctors and ward nurses, and the introduction of electronic prescribing, we achieved a significant change in practice, particularly in the prescribing of PRN antipsychotics, which has reduced our patients’ risk of receiving high dose antipsychotic medication.

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Cholestatic Liver Injury: Care of Patients With Primary Biliary Cholangitis or Primary Sclerosing Cholangitis

AACN Advanced Critical Care ◽

10.4037/aacnacc2016202 ◽

2016 ◽

Vol 27 (4) ◽

pp. 441-452 ◽

Cited By ~ 2

Author(s):

Laurie Larson ◽

Michelle James ◽

Andrea Gossard

Keyword(s):

Primary Sclerosing Cholangitis ◽

Sclerosing Cholangitis ◽

Disease Recurrence ◽

Outpatient Setting ◽

Primary Biliary Cholangitis ◽

Malignant Neoplasms ◽

Cholestatic Liver Disease ◽

Gallbladder Polyps ◽

Increased Risk ◽

Common Causes

The most common causes of chronic cholestatic liver disease are primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). Both disease processes are characterized by a destruction of intrahepatic and/or extrahepatic biliary ducts. The etiology is not entirely clear; however, there is an underlying autoimmune component contributing to both disease processes. Although PBC and PSC are often diagnosed and managed in the outpatient setting, in some instances, a patient may have jaundice, fatigue, and pruritus requiring evaluation and determination of the cholestatic cause. Patients with PSC should be monitored for evidence of cholangiocarcinoma, colon cancer, and gallbladder polyps as they are at an increased risk of malignant neoplasms. Liver transplant has the potential for improving quality of life, although disease recurrence is a risk.

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EP.WE.485An Audit to Investigate the Incidence of Face-to-Face Patient Review by GPs Prior to Referral to Surgical Assessment Unit

British Journal of Surgery ◽

10.1093/bjs/znab308.059 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Hannah Murray

Keyword(s):

Hospital Setting ◽

Electronic System ◽

Patient Risk ◽

Face To Face ◽

Increased Risk ◽

Assessment Unit

Abstract Aims Since COVID-19, GP’s have been encouraged to do fewer face-to-face consultations to prevent unnecessary patient contact1. Anecdotally, this initially resulted in many patients being referred to SAU who had not been seen by a GP, and then being discharged back to the community the same day, causing potentially increased risk of contracting COVID-19 through hospital attendance. The aim of this audit was to investigate the incidence of patients referred to SAU not seen by a GP and discharged the same day. Methods GP referrals were identified over a 7 day period through the surgical take electronic system Aramis©. The case notes and GP documentation were reviewed to identify whether a face-to-face GP consultation occurred, and then whether the patient was admitted to SAU or discharged the same day. Results During a 7 day period, there were 24 (n = 24) GP referrals of which only 3 (12.5%) were not seen by the GP, all of whom were admitted for at least one night. However, of the patients referred and seen by GP, 7 (29%) were discharged the same day. Conclusions This demonstrates that during this 7-day period, there was no incidence of inappropriate GP referral to SAU of patients not seen by a GP, and the majority of GP referrals warranted admission. This suggests that in most cases, GPs are avoiding unnecessary emergency surgical referrals and attempt to review patients face-to-face prior to referral, thus reducing patient risk of contact with COVID-19 in the hospital setting.

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AB1292-HPR NUMBER OF DRUGS IN THE PRESCRIPTION, A PREDISPOSING FACTOR FOR MEDICATION ERRORS IN RHEUMATOLOGY

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.2940 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1936-1936

Author(s):

L. Santoyo-Fexas ◽

R. A. Uriarte Botello ◽

B. R. Vázquez Fuentes ◽

C. V. Solis ◽

C. M. Skinner Taylor ◽

...

Keyword(s):

Medication Error ◽

Medication Errors ◽

Medical Errors ◽

Prescription Drugs ◽

Random Search ◽

Prescription Error ◽

Predisposing Factor ◽

Increased Risk ◽

The Difference ◽

Types Of Faults

Background:Medication error can be defined as a failure in the treatment process that leads to or has the potential to lead to harm to the patient, this fault can happen in two different phases: prescribing and prescription.Prescribing is the process of deciding what to prescribe and naming it. Various types of faults can occur in the decision-making process: underprescribing, overprescribing, irrational, inappropriate and ineffective prescribing. All these covers one type of errors, but these are different kind of errors that those that occur in the act of writing a prescription. This leads to the distinct concepts of ‘prescribing faults’ and ‘prescription errors’A prescription is ‘a written order, which includes detailed instructions of what medicine should be given, to whom, in what formulation and dose, by what route, when, how frequently, and for how long’. Thus, a prescription error can be defined as ‘a failure in the prescription writing process that results in a wrong instruction about one or more of the normal features of a prescription’. The ‘normal features’ include the identity of the patient, the identity of the drug, the formulation and dose, and the route, timing, frequency, and duration of administration. (1)It is not record about the rate of medication errors in rheumatology consultation.Objectives:To evaluate whether there is a relationship between prescribing errors and the number of drugs in the prescription.Methods:A descriptive, observational, and retrospective study was made.It was carried out a random search of medical prescriptions, generated by the electronic records (REPAIR®) of the rheumatology consultation of the Hospital Universitario “Dr. José Eleuterio González” during 2019, in which the prescriptions that contained any error were identifiedT student test was performed to see the difference in the prescription error based on the number of medications. P <0.05 was taken as statistically significant.Results:A review of 867 medical prescriptions was performed, among which 5503 medications were indicated with an average of 6.34 medications per prescription, a total of 30 (6.9%) prescriptions were found with error, where a total of 71 (3.9%) medications had errors. In the prescriptions with medication error, all the errors were prescription type; 68 (95.7%) had a mistake in the duration of administration and 3 (4.22%) in the identity of the drug.In the prescriptions with medical errors the average number of prescription drugs was 7.50, only 2/30 (0.6%) had less than 7 indicated medications (4 and 6), meanwhile the prescriptions in which no error was found had a mean of 6.30 indicated medications. P < 0.001.Conclusion:According to the study findings, it could be established that when the number of prescribed medications is greater than 7, there is an increased risk of making a prescription error. Further studies should carry out to look for other factors that influence medical errors in rheumatology clinics.References:[1]Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol. 2009;67(6):599-604.AcknowledgmentsDisclosure of Interests:None declared

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507 Outcomes After the Administration of Hydroxocobalamin

Journal of Burn Care & Research ◽

10.1093/jbcr/iraa024.139 ◽

2020 ◽

Vol 41 (Supplement_1) ◽

pp. S90-S90

Author(s):

Kaitlin A Pruskowski ◽

Leopoldo C Cancio

Keyword(s):

Hospital Mortality ◽

Hospital Stay ◽

Hospital Setting ◽

Kidney Injury ◽

Retrospective Chart Review ◽

Lactate Clearance ◽

Inhalation Injury ◽

Icu Admission ◽

Increased Risk ◽

Lactate Levels

Abstract Introduction Hydroxocobalamin is administered to patients after injures sustained during structure fires or fires in enclosed spaces. It is unknown how the administration of hydroxocobalamin affects patient outcomes, however, there have been reports of increased risk of acute kidney injury (AKI). The purpose of this study was to determine the population in which hydroxocobalamin is administered and to assess outcomes in patients who receive this medication in the ICU setting. Methods This was a retrospective chart review that included all patients admitted to the burn ICU between July 2016 and April 2019. Patients were included if they received hydroxocobalamin after ICU admission. Patients who received hydroxocobalamin in the pre-ICU or pre-hospital setting were not included in this analysis. Data collected included demographic information, number of hydroxocobalamin doses administered, burn size (% TBSA), presence of inhalation injury (II), lactate levels during the first 72 hours of hospitalization, carboxyhemoglobin levels, need for continuous renal replacement therapy (CRRT), and in-hospital mortality. Results Thirty-five patients received hydroxocobalamin after ICU admission. Patients were, on average, 48 ± 19 years old with a 25.5 ± 24.8% TBSA burn. Twenty-nine patients (82.9%) who received hydroxocobalamin in the ICU were diagnosed with II via bronchoscopy. The median 24-hour fluid resuscitation requirement was 7.4 mL/kg/% TBSA (IQR 4.6, 12.7). Twenty-two patients (63%) who received hydroxocobalamin developed AKI during the first 72 hours of admission. Twenty-one patients (60%) required CRRT during their hospital stay; 42.8% of patients were started on CRRT during the resuscitation period. The mean admission lactate level was 4.4 ± 2.3 mmol/L. On average, lactate clearance occurred in 34.6 hours; 11 (31.4%) patients did not clear lactate within 72 hours. One patient had a carboxyhemoglobin level greater than 10% on admission. Ten (28.9%) patients died during their hospital stay. Conclusions Most patients who receive hydroxocobalamin after ICU admission developed AKI within the first 72 hours. Further studies on the relationship between the administration of hydroxocobalamin and the development of AKI and in-hospital mortality are warranted. Applicability of Research to Practice The use of hydroxocobalamin may carry an increased risk of AKI. Providers should be aware of this risk when prescribing this medication.

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