Letter to the Editor
Medication Errors Among Inpatients Sir, A medication error is defined as “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.”1 These are among the most common medical errors, harming at least 1.5 million people every year. 2 Common types of medication errors are; incomplete patient information (allergies, co-medications, etc.), miscommunication of drug orders (due to poor handwriting, confusion between drug names, misuse of zeroes and decimal points, confusion of dosing units and inappropriate abbreviations), unavailable drug information etc.3 On observing some cases of improper execution of treatment orders, we conducted a pilot study to determine the commoner causes for medication errors in our set-up. A retrospective case-record review of all pyomeningitis cases admitted over a one-year period (27 January 2005 to 26 January 2006) was done at our pediatric teaching hospital. The patient case-sheets, resident round books, and the nursing-records of these cases were retrieved and specifically studied to see the timing of steroid use with respect to the time of first antibiotic dose. There had been a total of 30 children with a diagnosis of pyomeningitis and the treating physician had decided co-medication with steroids (30 minutes before the first dose of antibiotic) for 19 of these patients. However, directions to use steroids ‘30 minutes before antibiotics’ were mentioned by the resident physician in the treatment orders of only seven (36.8%) patients which were however, clearly written without any abbreviations. The steroids had been administered as per these directions in only four of these seven (57.1%) patients; when checked from the records maintained by the nursing staff. Thus, only 21% (4 of 19) children with pyomeningitis actually received steroids as per the treatment schedule prescribed. Medication errors may broadly be considered to include any deviation in the process from medication order through administration of the dose.4 At least one medication error is estimated to occur per hospital patient per day.2 Most medication errors have been attributed to documentation issues. 5 In the present study, poor communication between the senior and junior level
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physicians (failure to explain the significance of the said schedule and need to record the same), and between physicians and nursing staff (failure to record the schedule of steroid dose in the treatment orders) were responsible for the medication errors in 12 of 19 patients (63.2%). Incomplete and/or illegible prescriptions have previously also been reported to be an important reason for medication errors. 1,6 There were no illegible prescriptions in the present study. Of the remaining seven patients, 43% did not receive the treatment as prescribed because of the fixed injection administration schedule being used in the hospital. Although we reviewed a small number of cases of one particular regimen, this study documents a high prevalence of medication errors among the present group of pediatric in-patients; and highlights communication gaps as an important modifiable factor responsible for the same. As a follow-up, a more detailed study has been initiated and regular training of residents in prescription writing and, of nursing staff in carrying out medication orders has been started. Devendra Mishra and Shambhavi Seth Assistant Professor Department of Pediatric, Maulana Azad Medical College Delhi-110002 Chacha Nehru Bal Chikitsalaya, New Delhi, India E-mail :
[email protected] REFERENCES 1. U.S. Food and Drug Administration. Medication errors. Available from: URL: http://www.fda.gov/cder/drug/MedErrors. Accessed November 20, 2006. 2. The National Academies. News. Available from: URL: http:// www8. nationalacadem ies.org/onpinews/newsitem.aspx? RecordID=11623. Accessed November 20, 2006. 3. U.S. Food and Drug Administration. Strategies to reduce medical errors. Available from: URL: http://www.fda.gov/fdac/ features/2003/303_meds.html. Accessed November 20, 2006. 4. Marino BL, Reinhardt K, Eichelberger WJ, Steingard R. Prevalence of errors in a pediatric hospital medication system: implications for error proofing. Outcomes Manag Nurs Pract 2000; 4 : 129-135. 5. Deans C. Medication errors and professional practice of registered nurses. Collegian 2005; 12: 29-33. 6. Winslow EH, Nestor VA, Davidoff SK, Thompson PG, Borum JC. Legibility and completeness of physicians’ handwritten medication orders. Heart Lung 1997; 26 : 158-164.
Indian Journal of Pediatrics, Volume 75—September, 2008
