ArticlePaediatric drugs2021
A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children's Intensive Care.
Article in Paediatric drugs, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers, 1 of them a synthesis that pooled it.
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Who cites it
7 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis.Drug safety · 2022Pooled it
- Structuring medication safety narratives: development and evaluation of the medication-related incident reports annotation scheme.Frontiers in digital health · 2026Article
- Risk Factors Associated with Medication Administration Errors in Children: A Prospective Direct Observational Study of Paediatric Inpatients.Drug safety · 2024Observational
- Evaluation of the effect of a Nursing System Framework on Nurse Sensitive Indicators, mortality and readmission in an NHS Trust.Nursing open · 2023Observational
- Development and validation of a machine learning-based detection system to improve precision screening for medication errors in the neonatal intensive care unit.Frontiers in pharmacology · 2023Article
- Defining avoidable healthcare-associated harm in prisons: A mixed-method development study.PloS one · 2023Article
- Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.Therapeutic advances in drug safety · 2023Article
Corrections and comments
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Authors and funding
5 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundCritically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas.
objectiveThis study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs).
methodsWe carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents.
resultsIn total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols.
conclusionsNeonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.
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