Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study
Issued Date
2022-01-01
Resource Type
ISSN
11766336
eISSN
1178203X
Scopus ID
2-s2.0-85133597231
Journal Title
Therapeutics and Clinical Risk Management
Volume
18
Start Page
669
End Page
681
Rights Holder(s)
SCOPUS
Bibliographic Citation
Therapeutics and Clinical Risk Management Vol.18 (2022) , 669-681
Suggested Citation
Tansuwannarat P., Vichiensanth P., Sivarak O., Tongpoo A., Promrungsri P., Sriapha C., Wananukul W., Trakulsrichai S. Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study. Therapeutics and Clinical Risk Management Vol.18 (2022) , 669-681. 681. doi:10.2147/TCRM.S363638 Retrieved from: https://repository.li.mahidol.ac.th/handle/123456789/84120
Title
Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study
Author's Affiliation
Other Contributor(s)
Abstract
Purpose: 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.