Medication error trends and effects of person-related, environment-related and communication-related factors on medication errors in a paediatric hospital

Elizabeth Manias, Noel Cranswick, Fiona Newall, Ellie Rosenfeld, Carlye Weiner, Allison Williams, Ian C.K. Wong, Narelle Borrott, Jerry Lai, Sharon Kinney

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Aim: This study aimed to examine reported medication error trends in an Australian paediatric hospital over a 5-year period and to determine the effects of person-related, environment-related and communication-related factors on the severity of medication outcomes. In particular, the focus was on the influence of changes to a hospital site and structure on the severity of medication errors. Methods: A retrospective clinical audit was undertaken over a 5-year period of paediatric medication errors submitted to an online voluntary reporting system of an Australian, tertiary, public teaching paediatric hospital. All medication errors submitted to the online system between 1 July 2010 and 30 June 2015 were included. Results: A total of 3340 medication errors was reported, which corresponded to 0.56% medication errors per combined admissions and presentations or 5.73 medication errors per 1000 bed days. The most common patient outcomes related to errors requiring monitoring or an intervention to ensure no harm occurred (n = 1631, 48.8%). A new hospital site and structure had 0.354 reduced odds of producing medication errors causing possible or probable harm (95% confidence interval 0.298–0.421, P < 0.0001). Patient and family involvement had 1.270 increased odds of identifying medication errors associated with possible or probable harm compared with those causing no harm (95% confidence interval 1.028–1.568, P = 0.027). Interrupted time series analyses showed that moving to a new hospital site and structure was associated with a reduction in reported medication errors. Conclusion: Encouraging child and family involvement, facilitating hospital redesign and improving communication could help to reduce the harm associated with medication errors.

Original languageEnglish
Pages (from-to)320-326
Number of pages7
JournalJournal of Paediatrics and Child Health
Issue number3
Publication statusPublished - Mar 2019


  • family involvement
  • hospitalised child
  • interdisciplinary communication
  • medication error
  • patient involvement

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