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Phantakan Tansuwannarat,1,2 Piraya Vichiensanth,3 Ornlatcha Sivarak,4 Achara Tongpoo,2 Puangpak Promrungsri,2 Charuwan Sriapha,2 Winai Wananukul,2,5 Satariya Trakulsrichai2,3 1Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand; 2Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 3Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 4International College, Mahidol University, Nakhon Pathom, 73170, Thailand; 5Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Satariya Trakulsrichai, Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Rama VI Road, Bangkok, 10400, Thailand, Tel +66 2-2011084, Fax +66 2-2011086, Email satariya.tra@mahidol.ac.thPurpose: This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (< 15 years of age) treated in the hospital setting.Patients and Methods: We performed a 10-year retrospective study (January 2011âDecember 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome.Results: In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hourâ 14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs.Conclusion: Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.Keywords: children, deaths, outcomes, pediatrics |
