Effects of a pharmacist-led pediatrics medication safety team on medication-error reporting.
OBJECTIVE
The effects of a pharmacist-led pediatrics medication safety team (PMST) on the frequency and severity of medication errors reported were studied.


METHODS
This study was conducted in a pediatric critical care center (PCCC) in three phases. Phase 1 consisted of retrospective collection of medication-error reports before any interventions were made. Phases 2 and 3 included prospective collection of medication-error reports after several interventions. Phase 2 introduced a pediatrics clinical pharmacist to the PCCC. A pediatrics clinical pharmacist-led PMST (including a pediatrics critical care nurse and pediatrics intensivist), a new reporting form, and educational forums were added during phase 3 of the study. In addition, education focus groups were held for all intensive care unit staff. Outcomes for all phases were measured by the number of medication-error reports processed, the number of incidents, error severity, and the specialty of the reporter.


RESULTS
Medication-error reporting increased twofold, threefold, and sixfold between phases 1 and 2, phases 2 and 3, and phases 1 and 3, respectively. Error severity decreased over the three time periods. In phases 1, 2, and 3, 46%, 8%, and 0% of the errors were classified as category D or E, respectively. Conversely, the reporting of near-miss errors increased from 9% in phase 1 to 38% in phase 2 and to 51% in phase 3.


CONCLUSIONS
An increase in the number of medication errors reported and a decrease in the severity of errors reported were observed in a PCCC after implementation of a PMST, provision of education to health care providers, and addition of a clinical pharmacist.
Costello
Jennifer L
JL
Children's Hospital of New Jersey at Newark Beth Israel Medical Center, Newark 07112, USA. jcostello@sbhcs.com
Torowicz
Deborah Lloyd
DL
Yeh
Timothy S
TS
D006801:Humans; D008508:Medication Errors / Q000517:prevention & control; D010348:Patient Care Team; D010372:Pediatrics; D010595:Pharmacists; D012449:Safety