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Reported medication events in a paediatric emergency research network: sharing to improve patient safety
  1. Kathy N Shaw1,
  2. Kathleen A Lillis2,
  3. Richard M Ruddy3,
  4. Prashant V Mahajan4,
  5. Richard Lichenstein5,
  6. Cody S Olsen6,
  7. James M Chamberlain7,
  8. for the Pediatric Emergency Care Applied Research Network
  1. 1Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  2. 2Department of Pediatrics, Women and Children's Hospital of Buffalo, Buffalo, New York, USA
  3. 3Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  4. 4Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan, USA
  5. 5Department of Pediatrics, University of Maryland, Baltimore, Maryland, USA
  6. 6Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
  7. 7Division of Emergency Medicine, Children's National Medical Center, Washington, DC, USA
  1. Correspondence to Dr Kathy N Shaw, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104-1902, USA; Shaw{at}


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.

  • paediatrics
  • emergency department

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