Therapeutics and Clinical Risk Management (Jun 2022)
Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study
Abstract
Phantakan Tansuwannarat,1,2 Piraya Vichiensanth,3 Ornlatcha Sivarak,4 Achara Tongpoo,2 Puangpak Promrungsri,2 Charuwan Sriapha,2 Winai Wananukul,2,5 Satariya Trakulsrichai2,3 1Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand; 2Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 3Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 4International College, Mahidol University, Nakhon Pathom, 73170, Thailand; 5Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Satariya Trakulsrichai, Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok, 10400, Thailand, Tel +66 2-2011084, Fax +66 2-2011086, Email [email protected]: This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (< 15 years of age) treated in the hospital setting.Patients and Methods: We performed a 10-year retrospective study (January 2011–December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome.Results: In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour– 14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs.Conclusion: Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.Keywords: children, deaths, outcomes, pediatrics
