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5PSQ-138 Review of medication errors in a paediatric hospital based on an institutional reporting system
  1. C San1,
  2. G Bianconi1,
  3. JF Meyer1,
  4. A Minetti2,
  5. Y De Oliveira Granja2,
  6. L De Pontual3,
  7. JE Fontan1,
  8. S Kabiche1
  1. 1Hôpital Jean Verdier, Pharmacy, Bondy, France
  2. 2Hôpital Jean Verdier, Quality and Risk Management, Bondy, France
  3. 3Hôpital Jean Verdier, Paediatrics, Bondy, France


Background Medication errors occur more frequently and are more concerning in paediatric inpatients compared to adults. The main reasons are the difference in pharmacokinetics and in pharmacodynamics compared to adults and the heterogeneity of the paediatric population that implies a dose adjustment based on patient’s age, bodyweight or surface area. A review of medications errors could help us to improve care quality and patient safety.

Purpose To categorise medication errors that occurred in paediatric and neonatology units, and to identify their main causes.

Material and methods A retrospective review of medication errors was carried out based on the data extracted in the institutional reporting system between January 2017 and June 2018. Data were collected and analysed using Microsoft Excel. An Excel spreadsheet developed by the French Society of Clinical Pharmacy to review medication-related errors was used to perform the analysis. Analysis was performed by two pharmacists and a member of the quality and risk management department.

Results Of the 108 events reported in the system, 31 were medication errors that occurred in paediatric (24) and neonatology (seven) units. Medication errors occurred in every stage of the medication process including the logistics part, but 18/31 occurred during medication administration. The nurse was the professional who intercepted the most medication errors (25/31). 22/31 errors were not prevented and reached the patient, but none were life-threatening. However, 11/31 errors were considered as events that should not have occurred, also known as ‘never events’. Medications commonly involved in errors were injectable antibiotics (8/31). Main causes were: reading error (12), differences between prescribing and administration (11), lack of control before administration (eight), underestimation of risk factors (seven) and lack of training of the healthcare team (five).

Conclusion Medication errors are often discussed in experience feedback committees but are analysed individually. Our global analysis by using a standardised method has highlighted recurrent causes of errors. Improvement measures have been established and prioritised in order to design a multi-year programme to reduce the occurrence of medication errors. Our first interventions will focus on the training and awareness of medication errors to members of the healthcare team.

References and/or acknowledgements

No conflict of interest.

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