Pediatric Dose Calculation Issues and the Need for Human Factors–Informed Preventative Technology Optimizations.
Background: Dose calculation errors are one of the most common types of medication errors impacting children and they can result in significant harm. Technology-based solutions, such as computerized provider order entry, can effectively reduce dose calculation issues; however, these technologies are...
| Publicado en: | Patient Safety (2689-0143) Vol. 4; no. 2; pp. 48 - 62 |
|---|---|
| Autores principales: | , , , , , , , , , , , |
| Formato: | questionnaire/scale research tables/charts Journal Article |
| Publicado: |
Pennsylvania Patient Safety Authority
Jun2022
|
| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=158296568&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 158296568 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 26890143 N1OO jtl: Patient Safety (2689-0143) issn: 26890143 maglogo: N pubinfo: dt: Jun2022 vid: 4 iid: 2 pid: 50366 pub: Pennsylvania Patient Safety Authority place: Harrisburg, Pennsylvania artinfo: ui: 158296568 158296568 158296568 10.33940/data/2022.6.5 158296568 ppf: 48 ppct: 14 formats: fmt: @attributes: type: P tig: atl: Pediatric Dose Calculation Issues and the Need for Human Factors–Informed Preventative Technology Optimizations. aug: au: Russell, Jacqueline L. Grimes, Joanna P. Teferi, Sofia Pruitt, Zoe M. Howe, Jessica L. Adams, Katharine T. Nicol, Natasha Krevat, Seth Busog, Deanna Ratwani, Raj M. Jones, Rebecca Franklin, Ella S. affil: Research associate at the MedStar Health National Center for Human Factors in Healthcare and a general surgery resident at MedStar Health. sug: subj: Medication Errors In Infancy and Childhood Dosage Calculation Evaluation Patient Safety Electronic Order Entry Technology, Medical Human Female Male Child Record Review Medical Records Age Factors Sex Factors Medication Errors Prevention and Control Drug Administration Coding Electronic Health Records Descriptive Statistics Child: 6-12 years Female Male ab: Background: Dose calculation errors are one of the most common types of medication errors impacting children and they can result in significant harm. Technology-based solutions, such as computerized provider order entry, can effectively reduce dose calculation issues; however, these technologies are not always optimized, resulting in potential benefits not being fully realized. Methods: We analyzed pediatric dose-related patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System using a task-analytic approach that focused on information being used in the dose calculation, calculation errors during ordering, and errors during dose preparation or administration. From these reports, we identified whether the patient was impacted by the error, the type of medication involved, and whether a technology optimization could have mitigated the issue. Results: Of the 356 reports reviewed, 326 (91.6%) met the criteria for a dose calculation issue. The 326 reports meeting criteria had the following dose calculation issue types: wrong information used in the calculation (49 of 326, 15.0%), incorrect calculation during ordering (97 of 326, 29.8%), and calculated dose was not properly used or incorrect calculation during preparation/administration (180 of 326, 55.2%). Most of these dose calculation issues impacted the patient (219 of 326, 67.2%). Analysis of these issues by patient age group and drug class also revealed interesting patterns. Technology optimizations potentially could have addressed 81.6% of the dose calculation issues identified. Conclusion: While many healthcare facilities have adopted health information technology and other devices to support the medication process, these technologies are not always optimized to address dose calculation issues. Human factors–informed recommendations, a safety checklist, and test cases for optimizing technology are provided in the context of these findings. pubtype: Academic Journal doctype: questionnaire/scale research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
|---|