January 12, 2013 – A study involving nurses working on a total of 440 patient beds at three hospitals in eastern, central and western Canada found four deaths over a three-month span and an average of 20 drug-administration mistakes per paediatric hospital ward. The study, recently published in the 'Journal of Paediatric Nursing', also concluded that 10% of child patients reviewed at 22 hospitals who had suffered adverse events with medication related incidents ranked as the second largest source of problems behind surgery.
Kim Sears, a Queen's University Nursing Professor and the lead researcher said, "I saw four lethal errors which doesn't seem like very much, but that's four children who died. Each site had at least one child die in it during the three months, because of a medication. I had only 18 hospital wards in total – that's a very small sample."
Professor Sear's research is probably the first in Canada to look specifically at medication administration for paediatric patients and provides highly detailed circumstances as to how the problems occur. Nurses often prepare medication at the bedside and the quantities of drugs are so small that a dangerously large dose may not be readily noticeable, making the potential for disaster greater with child patients.
The survey recorded the following statistics:
- 372 errors over three months including 127 near misses and 245 actual errors
- 51 mistakes were graded as potentially lethal, 20 as serious, 112 as significant and 185 as minimal (4 mistakes were omitted or ungraded)
- Children receiving medication at the wrong time instead of within the recommended half hour window so as to avoid incorrect dosing was the most common mistake
Nurses noted that the mistakes were due to heavy workload, distractions and poor communications. Individual negligence is rarely to blame for such incidents rather the study suggests the causes were systemic. It's also important to note that some nursing schools do not offer paediatric rotations, so nurses that find employment at paediatric hospitals have little experience with children.
While hospitals are working hard to alleviate some of the problems the study urges for better designed work spaces with good lighting to prepare medications, improved communication between staff, and more widespread paediatric training for nurses to control the rate of errors.