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Effects of sharing information on drug administration errors in pediatric wards: a pre–post intervention study

Authors Chua SS, Choo SM, Sulaiman CZ, Omar A, Thong MK

Received 23 November 2016

Accepted for publication 19 February 2017

Published 23 March 2017 Volume 2017:13 Pages 345—353


Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 3

Editor who approved publication: Professor Garry Walsh

Siew-Siang Chua,1 Sim-Mei Choo,1 Che Zuraini Sulaiman,2 Asma Omar,3 Meow-Keong Thong3

1Department of Pharmacy, Faculty of Medicine, University of Malaya, 2Pharmacy Department, University Malaya Medical Centre, 3Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Background and purpose: Drug administration errors are more likely to reach the patient than other medication errors. The main aim of this study was to determine whether the sharing of information on drug administration errors among health care providers would reduce such problems.
Patients and methods: This study involved direct, undisguised observations of drug administrations in two pediatric wards of a major teaching hospital in Kuala Lumpur, Malaysia. This study consisted of two phases: Phase 1 (pre-intervention) and Phase 2 (post-intervention). Data were collected by two observers over a 40-day period in both Phase 1 and Phase 2 of the study. Both observers were pharmacy graduates: Observer 1 just completed her undergraduate pharmacy degree, whereas Observer 2 was doing her one-year internship as a provisionally registered pharmacist in the hospital under study. A drug administration error was defined as a discrepancy between the drug regimen received by the patient and that intended by the prescriber and also drug administration procedures that did not follow standard hospital policies and procedures. Results from Phase 1 of the study were analyzed, presented and discussed with the ward staff before commencement of data collection in Phase 2.
Results: A total of 1,284 and 1,401 doses of drugs were administered in Phase 1 and Phase 2, respectively. The rate of drug administration errors reduced significantly from Phase 1 to Phase 2 (44.3% versus 28.6%, respectively; P<0.001). Logistic regression analysis showed that the adjusted odds of drug administration errors in Phase 1 of the study were almost three times that in Phase 2 (P<0.001). The most common types of errors were incorrect administration technique and incorrect drug preparation. Nasogastric and intravenous routes of drug administration contributed significantly to the rate of drug administration errors.
Conclusion: This study showed that sharing of the types of errors that had occurred was significantly associated with a reduction in drug administration errors.

Keywords: drug administration error, medication error, intervention, sharing, pediatric

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