Three-step intervention can reduce pediatric drug errors


(HealthDay)—A three-step intervention addressing the diverse causes of medication errors can reduce these errors in a pediatric setting, according to a study published in the January issue of the Journal of Clinical Nursing.

Noting that one in five preventable adverse drug events in hospitalized children are caused by medication errors, Dorothee Niemann, from the University of Heidelberg in Germany, and colleagues developed a three-step intervention study including monitoring procedure. Pharmacists monitored drug handling by nurses on an 18-bed pediatric ward before and after each intervention step. Each intervention targeted distinct causes of errors, including knowledge deficits; rule violations and slips; and knowledge-, memory-, and rule-based errors, which were addressed in a handout, training course, and reference book.

The researchers found that after the third intervention, there was a decrease in the number of patients who were subjected to at least one medication error in drug handling, from 88 to 49 percent, and a decrease in the overall frequency of errors from 91 to 26 percent. There was a reduction in medication errors caused by knowledge deficits after issue of the handout; for example, errors regarding the correct volume of solvent for intravenous drugs decreased from 49 to 25 percent.

“Our three-step intervention reduced errors and is suitable to be tested in other wards and settings,” the authors write.

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Journal of Clinical Nursing