Medication Errors at Queen Sirikit National Institute of Child Health
V ARAPORN SANGTAW ESIN, MD*, WIBOON KANJANAPATTANAKUL, MD*, PANIDA SRISAN, MD*, WIPAJAREE NAWASIRI,BSC**, PORNSRI INGCHAREONSUNTHORN, MSC**
Affiliation : * Department of Pediatrics, **Department of Pharmacology, Queen Sirikit National Institute of Child Health, Bangkok 10400, Thailand.
Objective : To determine the incidence and type of medication errors, severity of events, patient outcomes and categories of drugs involved in the largest pediatric hospital in Thailand over a fifteen-month-period.
Patients and
Method : Retrospective review of in-patient medication errors documented in standard reporting forms from September 2001 to November 2002. Main outcome measure was the incidence of errors reported.
Results : Medication errors occurred in l per cent of admissions (322 errors of 32,105 admis sions). The most common error type was prescription error (35.40%). The majority of errors were detected and prevented before the drugs were administered (76.71 %). There was oniy one case of permanent brain damage; no deaths occurred in the study period. The most common group of drugs involved in medication errors was antibiotics and the most common route of administration was oral.
Conclusion : Medication errors are not uncommon. There is a need to change the behaviors of recognizing and acknowledging clinical errors, including drug errors. Careful review of errors high lights the many opportunities to change how drug errors are addressed and to make them less likely.
Keywords : Medication Errors, Queen Sirikit National Institute of Child Health
