P0559 / #1814: A MIXED-METHODS ANALYSIS OF MEDICATION SAFETY INCIDENTS REPORTED IN CHILDREN’S INTENSIVE CARE SETTINGS ACROSS ENGLAND AND WALES

Abstract

Aims & Objectives: Medication safety incidents may occur more frequently in children’s intensive care units (ICUs) than other clinical areas. System-wide learning from a national incident reporting system could support the identification of areas of risk to patients and the design of preventive strategies. This study aimed to determine the frequency, nature and contributory factors associated with medication-related safety incidents reported in children’s ICUs across England and Wales over a 9-year period. Methods: A retrospective mixed methods study using anonymised medication safety incident reports involving children (≤18 years of age) admitted to ICUs and submitted to the National Reporting and Learning System between 2010-2018. Content analysis of harmful incident reports was carried out to understand potential contributory factors involved in incidents. Results: A total of 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during medicines administration (13,668/25,567, 53.5%) and prescribing stages (7,412/25,567, 29%), and involved drug omission (4,812/25,567, 18.8%) and wrong dose (4,475/25,567, 17.5%) errors. Anti-infectives (6,483/25,567, 25.4%) were the most commonly implicated agents in the reports. 3,129 (12.2%) incidents were reported to cause patient harm. Common contributing factors to harmful incidents involved individual-related factors such as failure to adhere to policies, which were associated largely with organisation-related antecedents such as heavy workload and inadequate guidelines and systems (e.g. paper-based prescribing systems). Conclusions: This study adds understanding the environmental, organisational and inter-personal factors within which medication safety incidents arise. Clear targets for remedial interventions were identified and future research will need to focus on the treatment of infections and addressing systemic organisational factors.