title: Reported medication events in a paediatric emergency research network: sharing to improve patient safety.
abstract: OBJECTIVE
  Medication errors are an important cause of preventable morbidity, especially in children in emergency department (ED) settings. Internal use of voluntary incident reporting (IR) is common within hospitals, with little external reporting or sharing of this information across institutions. We describe the analysis of paediatric medication events (ME) reported in 18 EDs in a paediatric research network in 2007-2008.
  
  
  METHODS
  Confidential, deidentified incident reports (IRs) were collected, and MEs were independently categorised by two investigators. Discordant responses were resolved by consensus.
  
  
  RESULTS
  MEs (597) accounted for 19% of all IRs, with reporting rates varying 25-fold across sites. Anti-infective agents were the most commonly reported, followed by analgesics, intravenous fluids and respiratory medicines. Of the 597 MEs, 94% were medication errors and 6% adverse reactions; further analyses are reported for medication errors. Incorrect medication doses were related to incorrect weight (20%), duplicate doses (21%), and miscalculation (22%). Look-alike/sound-alike MEs were 36% of incorrect medications. Human factors contributed in 85% of reports: failure to follow established procedures (41%), calculation (13%) or judgment (12%) errors, and communication failures (20%). Outcomes were: no deaths or permanent disability, 13% patient harm, 47% reached patient (no harm), 30% near miss or unsafe conditions, and 9% unknown.
  
  
  CONCLUSIONS
  ME reporting by the system revealed valuable data across sites on medication categories and potential human factors. Harm was infrequently reported. Our analyses identify trends and latent systems issues, suggesting areas for future interventions to reduce paediatric ED medication errors.
authors.affiliation: Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-1902, USA. Shaw@email.chop.edu
authors.forename: Kathy N
authors.initials: KN
authors.lastname: Shaw
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Lillis
authors.forename: Richard M
authors.initials: RM
authors.lastname: Ruddy
authors.forename: Prashant V
authors.initials: PV
authors.lastname: Mahajan
authors.forename: Richard
authors.initials: R
authors.lastname: Lichenstein
authors.forename: Cody S
authors.initials: CS
authors.lastname: Olsen
authors.forename: James M
authors.initials: JM
authors.lastname: Chamberlain
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D033181:Information Dissemination; D008508:Medication Errors / Q000706:statistics & numerical data*; D061214:Patient Safety / Q000592:standards*; D036301:Qualitative Research; D012308:Risk Management / Q000706:statistics & numerical data*; D014481:United States
keywords: emergency department; paediatrics