T Badgery-Parker et al. J Pediatr 2024 272: 114087. Open Access! Child Age and Risk of Medication Error: A Multisite Children’s Hospital Study
Methods: This study from Australia included (1) prescribing errors identified from chart reviews from two hospitals as well as (2) medication administration errors assessed by direct prospective observation of 5137 administrations at a single hospital. In total, this study examined almost 70 000 medication orders and more than 5000 medication administrations.
Key findings:
- There was a modest increase in prescribing errors with age
- There was a high rate of errors across all age groups. The crude error rate for prescribing was 18.6/100 orders
- Hospital A had 14.5 prescribing errors per 100 orders using paper prescribing, and this increased to 17.6 per 100 orders during implementation of electronic prescribing then fell to 11.7 per 100 orders a year later.11 Prescribing error rates at hospital B were higher (28 per 100 orders in 2016, falling to 20 per 100 orders in 2020).
From the associated commentary (DM Goodman): “The Institute for Healthcare Improvement describe the 5 rights of medication administration –right patient, right drug, right dose, right route, and right time. But to achieve these goals, the right systems must also be in place.”
My take: This study makes me wonder what the error rate in our hospital is –I would think it would be much lower than the rates described in this study. This study makes me more appreciative of the occasional call I get from the pharmacist to adjust the dosing and the built-in alerts in our EMR.
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