PEDIATRICS Vol. 79 No. 5 May 1987, pp. 718-722
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Medication Error Prevention by Clinical Pharmacists in Two Children's Hospitals

Hugo L. Folli PharmD1, Robert L. Poole PharmD1, William E. Benitz MD1, and Janita C. Russo MD1

1 From the Pharmacy and Pediatrics Departments, Miller Children's Hospital, Memorial Medical Center, Long Beach, and Pharmacy and Pediatrics Departments, Stanford University Medical Center, Stanford, California

The purpose of this study was to record prospectively the frequency of and potential harm caused by errant medication orders at two large pediatric hospitals. The objective of the study was to assess the impact of pharmacist intervention in preventing potential harm. The study was conducted during a 6-month period. A total of 281 and 198 errors were detected at the institutions. The overall error rates for the two hospitals were 1.35 and 1.77 per 100-patient days, and 4.9 and 4.5 per 1,000 medication orders, respectively. Pediatric patients aged 2 years and less and pediatric intensive care unit patients received the greatest proportion of errant orders. Neonatal patients received the lowest rate of errant orders. The most common type of error was incorrect dosage, and the most prevalent type of error was overdosage. Antibiotics was the class of drugs for which errant orders were most common. Orders for theophylline, analgesics, and fluid and electrolytes, including hyperalimentation, were also frequently in error. In general, the error rate was greatest among physicians with the least training, but no physician group was error free. Involving pharmacists in reviewing drug orders significantly reduced the potential harm resulting from errant medication orders.

Key Words: medication error • clinical pharmacist • continuing education

Submitted on March 24, 1986
Accepted on June 17, 1986




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