Higher rate of ’near miss’ prescription errors in children

Posted on behalf of The Bell Law Firm, PLLC on Feb 02, 2011 in Wrongful Death

In a study reported this month in the Journal of Pain, researchers at a teaching hospital found that painkiller prescription errors were more common for pediatric patients. The researchers looked at 2,044 near-miss painkiller prescribing errors in an effort to learn more about the medication errors and the general characteristics of the medications that may contribute to those errors.

Among the types of errors examined were dose calculation mistakes and improper dose for type of administration (oral, intravenous, etc.); inappropriate use of dosage forms; insufficient knowledge of drug therapy; and failure to take patient-specific information into consideration in therapy decisions. The "near misses" were incidents detected, prevented and reported by pharmacists at the hospital.

Overall, there were 2.87 errors per 1,000 prescriptions. Of all errors, 0.63 per 1,000 were deemed potentially serious. For pediatric patients, 0.59 percent of the prescriptions contained one or more errors -- twice the rate for adults -- with 14 percent of those errors considered potentially serious.

The most errors occurred with commonly prescribed medications, but researchers found that less frequently prescribed drugs had higher error rates. Among the key factors contributing to errors were sound-alike drug names and painkillers used on an ongoing scheduled basis. Other key factors were modified dosage forms, atypical dosage courses of therapy and availability in dose forms for multiple administration routes.

The researchers believe their findings can help to shape patient and caregiver education as well as to augment patient safety strategies in hospitals and clinics. The U.S. Food and Drug Administration has been working on medication error issues, including name confusion, since 1992.

Source: US News, "Look-and-Sound-Alike Names Account for Many Painkiller Prescription Errors," 02/blog/11

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