Lavalle-Villalobos A, Payro-Cheng TJ, Martínez-Cervantes KA, Torres-Narváez P, Hernández-Delgado L, Flores-Nava G

Language: Spanish
References: 19
Page: 83-90
PDF size: 147.37 Kb.

ABSTRACT

Introduction. A medical error is the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim; it can generate extra costs for the hospital or the patient including permanent disability or death. Objective: To determine frequency and causes of error in medication. Predicated on the results of the first objective, the second objective, was to diminish prescribing errors by 50%, after applying the educational intervention which stressed preventive measures.
Material and methods. The study was carried out in 2 parts; the first part consisted of a retrospective study reviewing the records of hospitalized patients in different pediatrics services during a 2 months period. We quantified the percentage of errors in medication, type of error, drugs, day of the week, schedule, and administration way. Preventive measures were introduced and a second study was carried out in order to determine the impact of the educational intervention on the medical errors. We used descriptive statistics, chi square test and Student t.
Results. In the first part of the study we reviewed 232 charts; we identified prescription errors in 57.3% of the patient records. The total number of errors was 397, or 2.9 errors per chart. In the follow up study we reviewed 226 charts and detected prescription errors in only 17.6% of the charts. A total of 111 or 1.5 per chart. The decrease total errors 71% (P ‹ 0.05), but the decrease per chart was only a 3.5%.
Conclusion. The number of prescription errors identified in this study was inordinately high. Not surprisingly, the educational intervention which stressed preventive measures had a significant impact inreducing prescription errors during the period of study, stressing the need for continuous chart review to comply with quality assurance, and ensure patient safety.

REFERENCES

1. Leape LL, Berwick DM. Safe health care: are we up to it? BMJ. 2000; 320: 725-6.

2. Institute of Medicine. Committee on Quality Health Care in America. To err is human. Building a safer health system. Report of the Institute of Medicine. En: Kohn LT, Corrigan JM, Donaldson ME, editores. Washington DC: National Academy Press; 1999. p. 26-48.

3. Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: an user’s guide to the literature. Arch Dis Child. 2005; 90: 698-702.

4. Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child. 1998; 79: 56-8.

5. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285: 2114-20.

6. Ross LM, Wallace J, Payton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2003; 83: 492-7.

7. Taylor JA, Brownstein D, Christakis DA, Blackburn S, Strandjord TP, Klein EJ, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics. 2004; 114: 729-35.

8. Donosso A, Fuentes I. Efectos adversos en la UCIN. Rev Chil Pediatr. 2004; 75: 233-9.

9. Cheston M, Berlin C Jr, Mc Carver DG. Committee on Drugs and Committee on Hospital Care: Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 1998; 102: 428-30.

10. Schumock GT. Methods to asses the economic outcomes of clinical pharmacy services. Pharmacotherapy. 2000; 20 Supl 2: 2435-525.

11. American Academy of Pediatrics. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003; 112: 431-6.

12. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ. 2000; 320: 774-7.

13. Allnutt MF. Human factors in accidents. Br J Anaesth. 1987; 59: 856-64.

14. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligent in hospitalized patients. N Engl J Med. 1991; 324: 370-6.

15. Leape LL, Lawthers AG, Brenna TA, Johnson NG. Preventing medical injury. QRB Qual Rev Bull. 1993; 19: 144-9.

16. Bates DW, Cullen D, Lair N, Petersen LA, Small SD, Servi D, et al. Incidence of adverse drug events and potential adverse drug. JAMA. 1995; 274: 29-34.

17. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krisek C, Vargish T, et al. An alternative strategy for studying adverse events in medical care. Lancet. 1997; 349: 309-13.

18. Classen DC, Pestonik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997; 277: 301-6.

19. Bates DW, Spell N, Cullen D, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997; 277: 307-11.