Study Purpose/Objectives: The purpose of the study is to describe the medication error risk that exists within a system of medication use for a population of children with special health care needs requiring rehabilitative services. Specific study objectives are: · Identify type and frequency of medication errors associated with the prescribing of medications; · Identify type and frequency of medication errors associated with the administration of medications, including errors in transcription; · Identify type and frequency of medication errors associated with the dispensing of medications, including dispensing from automated dispensing machines; · Identify type and frequency of medication errors associated with the monitoring of medication therapy; · Classify medication errors according to severity levels; and, · Identify factors associated with increased risk of medication error.
Study Design: The study involves a retrospective document review of (a) medical charts; (b) Medication Administration Records; (c) pharmacy patient profiles; (d) pharmacy dispensing records; and (e) occurrence reports for medication error.
Population, Sample, Setting, Years: The study site is a small pediatric rehabilitation facility located in a large metropolis. The facility offers a number of inpatient and outpatient services. The mission of the facility is to provide rehabilitative care for children ages 0-21 with a long-term illness and/or developmental handicaps enabling children to transition from an acute care setting to the community more easily. For June 2001, the average daily inpatient census was 55. For January-June of 2001, the average length of stay was 73 days. A random sample of 14 charts from Unit A, 15 charts from Unit B, and 9 charts from Unit C have been selected into the study sample using the last four digits of the medical record number and a random numbers generator. The sample represents approximately 75% of the population on Units A and B and 100% of the population on Unit C. All charts from Unit C are included in the study due to the smaller number of beds in Unit C. A minimum of 300 patient days are currently being reviewed.
Concept Studied: The study evaluates the medication error risk that exists within a system of medication administration. Medication error risk includes both actual errors and the risk (or potential) for errors. Medication error as defined by the National Coordinating Council for Medication Error Reporting and Prevention is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer . . .all medications—including potential errors [are] of equal importance” (Medication Errors Council Revises and Expands Index for Categorizing Errors: Definition of Errors Broadened, June 12, 2001).
Methods: A 2-week period was identified for medical and institutional records’ review. Within this period, 10 days were identified for data collection. Using The Medication Safety Risk Assessment Part I and Part II Internal Benchmarking Tool©, records are being audited for a 24-hour period for each of these 10 days. Both weekdays and weekend days are included. Patient, hospital and unit demographic data have been collected as well as documentation on unit activity data during this two-week period. Data Analysis. Data analysis will include descriptive statistics on the number, type, and severity of medication errors identified. Errors will be classified into “types” based on The Hospital for Sick Children Confidential Medication typology. “Severity” of error will be classified using The Hospital for Sick Children Severity Level Medication Error scale. An error rate will be calculated based on the number of errors per 100 patient days and per 1,000 medication orders. Comparisons will be made between shifts, weekend vs. weekday patient days, patient demographics and the frequency and types of error. Environmental factors such as unit activity will be examined to determine any trends in activity and error frequencies.
Findings: Data collection will be completed at the end of this month.
Conclusions: None to date.
Implications: None to date.
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