Cross-sectional study identifying high-alert substances in medication error reporting among Swedish paediatric inpatients.

Abstract

The aims were to characterise paediatric medication errors and to identify the prevalence of known high-alert substances in these errors. All paediatric drug-related incident reports and complaints nationally reported to the Health and Social Care Inspectorate in Sweden 2011-2017 regarding inpatients were characterised by context and modal details. In addition, drug use at a university hospital was matched to local incident reports. Drug substances were classified using three high-alert lists. On a national level, there were 160 reports (2.5 per 10000 patients) in which the three high-alert lists were found in different degrees (17/35/47%). Morphine (n=12), vancomycin (n=11) and potassium (n=7) were most frequently involved. Eighty per cent of the reports concerned patients aged 0-6years. Intravenous was the most common route of administration (66%). On a university hospital level, the prevalence of all types of drug incidents reports was 1.7% among all inpatients. The prevalence of local incident reports involving high-alert substances was almost double that of non-alert substances. Existing high-alert drug lists are relevant for paediatric inpatients. A higher awareness and usage of such lists among hospital staff prescribing, dispensing and administering drugs to children may have the potential to reduce medication errors.