The effectiveness of the medication error review process at a tertiary pediatric hospital
C Rowe, G Koren
BACKGROUND: Medication errors, common in pediatric medicine, have the potential for serious morbidity and mortality. A common reason for this iatrogenia is miscalculation due to decimal point errors and erroneous computation. A previous study from the authors' institution showed that a subgroup of medical trainees commit 10-fold computational errors that are likely to be life-threatening in the pediatric population. For this subgroup especially, a mechanism needs to catch these errors before they reach the patient.
OBJECTIVE: To examine whether the medication error review process is working effectively in correcting drug errors.
SETTING: A tertiary pediatric hospital in Toronto, Ontario.
METHODS: Medication incident reports filed between October 1, 1994 and June 30, 1995 were reviewed for actual and potential (ie, intercepted) errors. RESULTS: An average of 73 medication reports were filed each month; the majority were actual errors. Only 48% of these were reviewed by the appropriate staff physician. Nurses were responsible for 77% of these errors, pharmacists 12% and physicians 11%. The rates of appropriate review and remedial action for nurses and pharmacists were 76% and 87%, respectively. For physicians, it was significantly lower at 38% (P<0.01).
CONCLUSIONS: The medication error review process is not functioning effectively on either the initial staff review or remedication. These flaws may explain the lack of improvement in rates of medication errors.