The rate of drug treatment error in children is low but could be reduced further, say researchers at the Royal Hospital for Sick Children in Glasgow.
In a retrospective review of medication errors in their hospital over five years from 1994 to 1999, Dr Linda Ross (department of child health) and colleagues found that the overall error rate was only one per 662 admissions (0.15 per cent). Errors involving the intravenous route were most common (56 per cent), with antibiotics being the most frequently involved drugs (44 per cent).
Fifteen of the recorded errors (8 per cent) had involved a 10-fold dosage adjustment. Reasons why these had occurred included miscalculation of the dose both before and after the prescribing stage, inaccurate verbal communication and errors in setting the pump rate on an infusion pump. The researchers point out that, despite the errors, there are still 16 different types of syringe pump in use throughout the hospital.
During the period under review, it had become pharmacy policy that two people should check all drug dispensing, they say. In the 22-month period before this time, 18 reported errors (9.8 per year) were attributed to drug dispensing. Only 21 (six per year) occurred in the subsequent 43 months.
Five errors involving morphine sulphate had occurred before July, 1998. As a result, it was decided that only one strength of morphine sulphate ampoules would be stocked in the hospital instead of three. In
addition, the neonatal intensive care unit changed to using syringes of morphine sulphate made up by pharmacy staff, at a concentration of 50µg/ml. The researchers point out that, since these changes, no further errors involving morphine have been reported.
The researchers conclude that, as most errors arise from organisational failures, rather than from personal negligence, a shift from a culture of blame to one of reflection on why systems failed was needed (Archives of Disease in Childhood 2000;83:492).
In an accompanying leading article Professor Terence Stephenson (professor of child health, Queen's Medical Centre, Nottingham) says: "The provision of drugs in appropriate concentrations and formulations would help avoid some of these errors. "Commenting on what individual practitioners could do to reduce errors he included avoiding decimal points or, when they were unavoidable, using a zero before the decimal point and avoiding unnecessary zeros after it, spelling out micrograms and nanograms in full and avoiding the use of abbreviations (ibid p496).