Rate Of Dosing Errors Research Articles

The Impact of a Pediatric Antibiotic Standard Dosing Table on Dosing Errors

The goal of this study was to compare the rate of dosing errors for antibiotic orders in pediatric patients before and after the implementation of an antibiotic standard dosing table with precalculated dosage for different weight ranges at a tertiary care hospital. A retrospective study of 300 antibiotic prescriptions for pediatric patients in three different settings (ambulatory care, inpatient, and emergency department) at a tertiary care hospital assessed the appropriateness of antibiotic dosing. The need for an antibiotic dosing standardization policy was identified after finding that more than 30% of patients experienced a dose variation of ±10% of the recommended daily dose. An antibiotic dosing standardization policy was implemented with an antibiotic standard dosing table for different weight ranges, and a hospital wide-education program was conducted to increase awareness of this new practice and its benefits. Three months after implementation, a random sampling of 300 antibiotic prescriptions collected from the same settings as the pre-intervention period was evaluated for compliance with the new policy and its effect on the number of antibiotic dosing errors. Six hundred prescriptions were included in this study (300 in the pre-implementation phase and 300 in the post-implementation phase). Patient characteristics were similar in both groups in terms of sex, age, and weight. Physician compliance with the antibiotic dosing standardization policy after its implementation was 62%. The dosing standardization policy reduced the rate of dosing errors from 34.3% to 5.06% (p=0.0001), and weight documentation on the antibiotic prescription improved from 65.8% to 85.7% (p=0.0001). Implementation of an antibiotic dosing standardization policy significantly reduced the incidence of dosing errors in antibiotics prescribed for pediatric patients in our hospital.

The effect of a computerized pediatric dosing decision support system on pediatric dosing errors

Children are more susceptible to medication errors because of differences in pharmacokinetics and pharmacodynamics compared to adults. Weight changes are common with growth in children and computer systems frequently are not updated with current information, which result in inaccurate weight-based dosing and thus harm children. This study evaluated the impact of a Computerized Physician Order Entry system with standardized pediatric dosing decision support (PDDS) function on reducing pediatric dosing errors. Outpatient prescriptions were analyzed from January to March during 2010 and 2011. The total number of pediatric prescriptions was 72,431 and 80,532 prior to and after system implementation, respectively. Out of 72,431 prescriptions, 1617 (2.23%) dosing errors were retrospectively detected by the system, whereas 15 dosing errors (0.02%) were detected by pharmacists prior to system implementation. Incorporating the system into practice resulted in a total of 210 successfully blocked dosing near misses, including 14 potentially fatal and 11 serious near misses. The final dosing error rate was significantly reduced from 2.23% to 0.66% (p < 0.001). A 10-fold increase of the near miss correction rate (0.02% vs. 0.26%, p < 0.001) was observed. The Computerized Physician Order Entry system with standardized pediatric dosing decision support system provided real-time warning and significantly decreased the dose error rate among pediatric patients.

Improving patient safety by minimizing chemotherapy dosing errors.

99 Background: Medication dosing errors in adult outpatient settings continues to be a significant source of morbidity. One recent study reported that approximately 7% of adult patients receiving chemotherapy experience medication errors (Kathleen E. Walsh, et al. Medication Errors Among Adults and Children with Cancer in the Outpatient Setting, Journal of Clinical Oncology, 2009). In 2011, New Century Health implemented a quality improvement project focused on minimizing chemotherapy medication errors. This study describes the oncology quality management program used with the Midwestern oncology providers of a large health plan. Methods: An analysis determined the overall medication dosing error rate and the number of oncologist-to-oncologist interventions. In addition, the root cause of each medication error was identified. Results: During the course of the year, 2,395 chemotherapy treatment plans were reviewed for compendia alignment. In 235 cases, the plans did not align with compendia, were identified for peer-to-peer consultation and were voluntarily withdrawn by the prescriber. Evidence-based plans were subsequently resubmitted for approval. Of the original treatment plans, 68 contained dosing errors. The most common dosing errors included: frequency (60.3%); sub-therapeutic (13.1%); super-therapeutic (14.7%); and loading dose for continuation (10.3%). The full year 2011 medication error rate was 2.8%. Conclusions: The integration of clinical decision support tools for dosing verification with oncologist-to-oncologist clinical review improved patient safety by identifying serious errors prior to treatment. These findings underscore the issue that many chemotherapy medication errors are preventable and arguably the medication error rate should be zero. [Table: see text]

Prescribing Errors in a Pediatric Emergency Department

To determine the frequency, prescriber, and type of prescribing errors in written in-house orders and ambulatory prescriptions in a pediatric emergency department (PED). A 17-day retrospective chart review and a 6-month retrospective ambulatory prescription review in a PED for medications with weight-based dosing. Orders and prescriptions were checked for prescriber identification number, route, weight-based target dose in milligrams per kilogram, frequency, correct dosing, and drug allergies. Narcotics were excluded from the prescription analysis. Forty-seven (12.5%) of 377 in-house orders and 37 (19.4%) of 191 individual charts contained at least 1 error: 4 (1.1%) orders contained an incorrect dose, 41 (10.8%) were written incorrectly, and 2 (0.5%) contained an incorrect dose and were written incorrectly. Thirty (4.3%) of 696 ambulatory prescriptions contained 1 error: 14 (2.0%) contained an incorrect dose, and 16 (2.3%) were written incorrectly. Pediatric postgraduate year-3 residents had the highest in-house order incorrect dose error rate (1 of 29 orders or 3.5%), and ED pediatric postgraduate year-2 residents had the highest ambulatory prescription incorrect dose error rate (6 of 66 prescriptions or 9.1%). Pediatric ED attending physicians had the highest error rates for writing orders and prescriptions incorrectly, 25% (3 of 12) and 9.7% (3 of 31), respectively. Antibiotics, analgesics, and narcotics were most often involved in errors. Prescribing errors are common in both written in-house orders and ambulatory prescriptions in a PED. Targeting safety interventions toward groups with less practice in prescribing pediatric doses and reeducating groups on safe medication writing techniques could decrease this error rate.

Emergency Medical Services System Changes Reduce Pediatric Epinephrine Dosing Errors in the Prehospital Setting

The goal was to describe the change in the rate of epinephrine dosing errors in the treatment of pediatric patients in prehospital cardiopulmonary arrest after the Los Angeles County Emergency Medical Services Agency instituted a program in which paramedics were required to use the Broselow tape and to report color zone categories to the base station and base stations were given and instructed formally in the use of the color-coded drug dosing chart. An observational analysis of a natural experiment was performed. Children < or = 12 years of age who were determined to be in prehospital cardiopulmonary arrest and who received prehospital epinephrine treatment by paramedics, in the periods of 1994 to 1997 and 2003 to 2004, were included in the study. In the 1994 to 1997 cohort, we identified 104 subjects in prehospital cardiopulmonary arrest who received epinephrine with a documented weight and route of administration. Only 29 of 104 subjects in the 1994 to 1997 cohort received the correct dose, whereas 46 of 104 subjects received a first dose within 20% of the correct dose. In the 2003 to 2004 cohort, we identified 41 children < or = 12 years of age who were in cardiopulmonary arrest and received prehospital epinephrine treatment but 4 children were excluded, leaving 37 subjects. Twenty-one of 37 subjects received the correct dose, whereas 24 of 37 subjects received a dose within 20%. The odds ratio for obtaining the correct epinephrine dose after the system changes versus before was 3.0, and that for obtaining a dose within 20% of the correct dose was 2.5. The program seems to have resulted in reduction of the rate of epinephrine dosing errors in the prehospital treatment of children in cardiopulmonary arrest in Los Angeles County.

Computer Calculated Dose in Paediatric Prescribing

Medication errors are an important cause of hospital-based morbidity and mortality. However, only a few medication error studies have been conducted in children. These have mainly quantified errors in the inpatient setting; there is very little data available on paediatric outpatient and emergency department medication errors and none on discharge medication. This deficiency is of concern because medication errors are more common in children and it has been suggested that the risk of an adverse drug event as a consequence of a medication error is higher in children than in adults. The aims of this study were to assess the rate of medication errors in predominantly ambulatory paediatric patients and the effect of computer calculated doses on medication error rates of two commonly prescribed drugs. This was a prospective cohort study performed in a paediatric unit in a university teaching hospital between March 2003 and August 2003. The hospital's existing computer clinical decision support system was modified so that doctors could choose the traditional prescription method or the enhanced method of computer calculated dose when prescribing paracetamol (acetaminophen) or promethazine. All prescriptions issued to children (<16 years of age) at the outpatient clinic, emergency department and at discharge from the inpatient service were analysed. A medication error was defined as to have occurred if there was an underdose (below the agreed value), an overdose (above the agreed value), no frequency of administration specified, no dose given or excessive total daily dose. The medication error rates and the factors influencing medication error rates were determined using SPSS version 12. From March to August 2003, 4281 prescriptions were issued. Seven prescriptions (0.16%) were excluded, hence 4274 prescriptions were analysed. Most prescriptions were issued by paediatricians (including neonatologists and paediatric surgeons) and/or junior doctors. The error rate in the children's emergency department was 15.7%, for outpatients was 21.5% and for discharge medication was 23.6%. Most errors were the result of an underdose (64%; 536/833). The computer calculated dose error rate was 12.6% compared with the traditional prescription error rate of 28.2%. Logistical regression analysis showed that computer calculated dose was an important and independent variable influencing the error rate (adjusted relative risk = 0.436, 95% CI 0.336, 0.520, p < 0.001). Other important independent variables were seniority and paediatric training of the person prescribing and the type of drug prescribed. Medication error, especially underdose, is common in outpatient, emergency department and discharge prescriptions. Computer calculated doses can significantly reduce errors, but other risk factors have to be concurrently addressed to achieve maximum benefit.

Incidence and nature of dosing errors in paediatric medications: a systematic review.

In paediatric medicine, drug doses are usually calculated individually based on the patient's age, weight and clinical condition. Therefore, there are increased opportunities for, and a relatively high risk of, dosing errors in this setting. Consequently, a systematic literature review using several databases was conducted to investigate the incidence and nature of dosing errors in children; 16 studies were found to be relevant. Eleven of the 16 studies found that dosing errors are the most common type of medication error, three of the remaining studies found it to be the second most common type. This review of published research on medication errors therefore suggests that dosing errors are probably the most common type of error in the paediatric population. In addition, there was a great variation in the error rates reported; this is likely to be due to the differences in the medication error definitions and methodologies employed. For example, the dosing error rate determined using spontaneous reporting ranges from 0.03 per 100 admissions in the UK to 2 per 100 admissions in the US. Extrapolating this, if the under-reporting rate is about 1 in 100, then the true incidence would be around 50,000 paediatric dosing errors per year in England. The information available shows that dosing errors are not uncommon and that 10-fold overdoses caused by calculation errors have led to serious consequences. There is an urgent need to develop methods to reduce medication errors in children and dosing errors should be the first priority.

Calculation of the Estimated Creatinine Clearance in Avoiding Drug Dosing Errors in the Older Patient

The population of hospitalized older patients is increasing. We investigated whether clinicians accurately detected renal insufficiency in older patients and chose correct doses of commonly prescribed antibiotics. We conducted a retrospective chart review of 1044 patients > 80 years admitted to the University of California Davis Medical Center between January and December 1997 with a diagnosis of infection. Inclusion criteria included data necessary to calculate creatinine clearance using the Cockroft-Gault equation and administration of any of the study antibiotics. Patients with unstable renal function, defined as an increase in creatinine of > or = 1.0 mg/dL/day were excluded. Administered dosages of each study drug were compared with the appropriate adjusted doses. We examined the variables of age, weight, serum creatinine, and sex to determine whether any were individually predictive of dosing errors. Dosing errors were identified in all of the antibiotics studied, and the overall dosing error rate was 34%. The factors that were predictive of dosage errors were advanced age and low body weight. Serum creatinine and sex were not statistically significant factors. Widespread errors in medication dosing are made in elderly hospitalized patients. The Cockroft-Gault equation reveals significant renal insufficiency requiring dose adjustments in most elderly patients studied, especially those > 85 years of age and with low body weight. Estimation of glomerular filtration rate should be performed routinely on all admitted patients older than 80 and in any patient with low lean body mass.

Human errors in the calculation of monitor units in clinical radiotherapy practice

Human mistakes are an important source of error in all steps of radiotherapy planning and their incidence should be investigated. As has been recognized by different authors and by the ICRU [4], the human error rate in the calculation of monitor units (MU) is relatively high. At our institute, we measured the human error rate in the calculation of MU by an independent check of the calculation. From September 1991 to June 1992 we identified and corrected 17 serious errors (deviation from the prescribed dose ≥ 5%) over 890 controls (l.9%) (daily dose errors). We also found a serious global dose error rate (i.e. the errors induced on the total reference dose for the complete course of the treatment) of l.3% ( 9 685 ) during the period November 1991–June 1992. These values suggest the importance of human errors in the calculation of MU and also confirm the validity of the independent check of MU calculation as one of the simplest ways of avoiding erroneous dose delivery by incorrect calculation of MU.