title: Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.
abstract: OBJECTIVE
  To determine the incidence, type, and stage of occurrence of medication errors and potential and actual adverse drug events (ADEs) in a pediatric intensive care unit (ICU) using trained observers. The preventability and severity of ADEs and the system failures leading to medication error occurrence were also investigated.
  
  
  METHODS
  Prospective, direct observation study.
  
  
  METHODS
  A 16-bed pediatric medical/surgical ICU at a tertiary care academic medical center.
  
  
  METHODS
  One enrolled nurse caring for at least one pediatric ICU patient age <18 yrs was randomly chosen during each observation period.
  
  
  METHODS
  Observers would intervene only in the event that the medication error would cause substantial patient harm or discomfort.
  
  
  RESULTS
  Medication errors and potential and actual ADEs were identified throughout the entire medication use process. The 26 12-hr observation periods included 357 reviewed written orders and 263 observed doses. The study observers identified 58 incidents, which were subsequently classified by the evaluators according to clinical importance, severity, and preventability. Fifty-two of these incidents were considered medication errors; six incidents were determined to be nonpreventable ADEs. Of the 52 medication errors, 42 (81%) were considered clinically important. Potential ADEs comprised 35 (83%) of these important medication errors; the other seven (17%) were classified as actual, preventable ADEs. Overall, the actual and potential ADE rate occurred at 3.6 events and 9.8 events per 100 orders, respectively.
  
  
  CONCLUSIONS
  Our medication error rate was similar to that of previous pediatric ICU studies that used the direct observation method for reporting but higher than the rates in previous studies using other detection techniques such as voluntary incident reporting. Periodic direct observation and other ongoing data collection methods such as voluntary incident reporting have the potential to be complementary approaches to medication error and ADE detection.
authors.affiliation: Medical Intensive Care Unit, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
authors.forename: Mitchell S
authors.initials: MS
authors.lastname: Buckley
authors.forename: Brian L
authors.initials: BL
authors.lastname: Erstad
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Kopp
authors.forename: Andreas A
authors.initials: AA
authors.lastname: Theodorou
authors.forename: Gail
authors.initials: G
authors.lastname: Priestley
mesh_terms: D000046:Academic Medical Centers; D001130:Arizona / Q000453:epidemiology; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D006801:Humans; D015994:Incidence; D015278:Intensive Care Units, Pediatric; D008297:Male; D008508:Medication Errors / Q000145:classification / Q000517:prevention & control / Q000706:statistics & numerical data*; D011446:Prospective Studies