RT Journal Article SR Electronic T1 Reported medication events in a paediatric emergency research network: sharing to improve patient safety JF Emergency Medicine Journal JO Emerg Med J FD BMJ Publishing Group Ltd and the British Association for Accident & Emergency Medicine SP 815 OP 819 DO 10.1136/emermed-2012-201642 VO 30 IS 10 A1 Kathy N Shaw A1 Kathleen A Lillis A1 Richard M Ruddy A1 Prashant V Mahajan A1 Richard Lichenstein A1 Cody S Olsen A1 James M Chamberlain A1 for the Pediatric Emergency Care Applied Research Network YR 2013 UL http://emj.bmj.com/content/30/10/815.abstract AB 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.