Abstract PCCLB-45: MEDICATION MISADVENTURES: WHAT, WHY AND BY WHOM?

Abstract

Aims & Objectives: Various types of medication errors (MEs) 1. prescribing error 2. administration error 3. monitoring error and 4. dispensing error with different classes of severity (NCC MERP scale) are common in hospitals. Prescription and administration errors can be reduced by targeted awareness program for medical and nursing cadre respectively. Aim of this ongoing study is to assess the incidence and determinants of medication errors and adverse drug events (ADEs) among hospitalized children and to identify the staff cadre that needs more focused education and observation strategy to reduce MEs. Methods Ongoing prospective observational study. Interim analysis was done on first 70 patients Results Mean age of patients was 6.2 years with M: ratio of 1.32:1. Out of 4975 doses, 284 MEs were detected with incidence of 56 per 100 patient days and 57 per 1000 medication doses. No patient developed adverse drug events (ADEs) so far. Highest severity of the errors was in Category C of NCC MERP (error occurred that reached the patient but did not cause patient harm). Prescriptions error (259: 91.2%), attributable to medical staff cadre was most common type of error followed by administration error (25: 8.8%), attributable to nursing staff cadre. Among prescribing errors, orders not being written in block letters or with illegible writing was the most common error (43.5% of total errors) followed by missing stop date (Figure 2). Conclusions MEs are common among hospitalized children, and prescription error is most common type suggesting need of awareness and knowledge enhancement programs for medical personnel.