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390 Medication errors and near-misses in a pediatric emergency department: a retrospective review
  1. Ann Loh,
  2. Sung Shin Teng,
  3. Khai Pin Lee,
  4. Sashikumar Ganapathy
  1. Singapore


Background Medication errors (MEs) are a significant cause of preventable morbidity and mortality. The paediatric emergency department (ED) is a high-risk setting with high patient volume and acuity of care, serving a uniquely susceptible population where weight-based calculations render them vulnerable to dosing errors. Medications are also often kept in stock, and are not audited by a pharmacist prior to administration. Stress, noise, time pressures, and unfamiliarity with paediatric conditions amongst rotating trainees compound this risk.

Objectives To describe the occurrence and type of MEs in pediatric ED and to identify contributing factors.

Methods A retrospective review of all reported MEs in Singapore’s largest tertiary pediatric ED from January 2013 to December 2019. MEs were reported via Risk Management System (RMS), while near-misses were extracted from RMS and the pharmacy department’s Closed Loop Medication Management System. Descriptive statistics were used to present ME types, severity and contributing factors.

Results Of 101 MEs reported in RMS, 59% were related to wrong dose, 22% to wrong medication and 6% to wrong patient. Wrong doses were related to duplicate dose (48%), wrong weight (20%), 10-fold errors (5%) and calculation errors (5%). Majority of MEs occurred during drug administration (52%), followed by prescription (30%) and transcription of medications (12%). Most commonly involved medications in MEs were anti-pyretics (33%), those for respiratory conditions (15%) and analgesics (13%). Of the MEs, 9 (9%) were serious errors requiring enhanced monitoring and/or intervention, while 1 (1%) caused temporary patient harm. Human factors (92%) was the most frequently documented contributing factor, namely failure to comply with established workflows, accurate information provided by guardians, and distractions.

Conclusions We have described a low incidence of MEs from 2013 to 2019. Strategies should be developed to ameliorate MEs in the pediatric ED. Areas for focused intervention should include systematic evaluation of drug administration and prescription processes, to enhance compliance with established procedures of checking (amongst the healthcare team and with guardians) and putting safeguards in place to minimize the impact of distractions in the ED setting.

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