Study on risk points of medication errors in pediatric patients with digoxin therapy

Abstract

Objective To investigate the possible risk points of medication errors in process of digoxin therapy in pediatric patients. Methods The doctors, nurses, pharmacists, and patients involved in process of digoxin therapy in Beijing Children′s Hospital, Capital Medical University, Dalian Children′s Hospital of Dalian Medical University, and Children′s Hospital of Nanjing Medical University were investigated by questionnaires, and the places involved were investigated on-the-spot. According to the results of questionnaires, on-the-spot investigation, and bibliographic search, the possible risk points of medication errors in process of digoxin therapy in pediatric patients were analysed using method of failure mode and effect analysis. The risk priority numbers (RPN) were calculated and sorted from high to low. The risk points with higher RPN scores were deemed to be the high frequency ones in process of digoxin therapy in pediatric patients. Results A total of 33 risk points were found from 4 links, including doctor prescribing, drug dispensing, nurse dispensing, and patient medication. The results of RPN sorting showed that the risk point with the highest RNP scores in doctor prescribing was special note absence for digoxin in hospital information system (67.5); the risk scores point with the highest PRN scores in drug dispensing was inaccurate dose occurred when digoxin was divided into small parts (74.7); the risk point with the highest PRN scores in nurse dispensing was that the digoxin was not kept in a dark place in ward medicine cabinet (15.2); the risk point with highest PRN scores in medication process was that the children′ guardians were not clear about the clinical manifestations of digoxin overdose(47.5). Conclusion Special note absence for digoxin in hospital information system, inaccurate dosage of digoxin when divided into small parts, improper storage of digoxin in the ward, and lack of knowledge about the clinical manifestations of digoxin overdose are probably the high frequency risk points of medication errors in process of digoxin therapy in pediatric patients. Key words: Digoxin; Pediatrics; Medication errors; Healthcare failure mode and effect analysis; Risk management