• Paula Otero, Andrea Leyton, Gonzalo Mariani, José María Ceriani Cernadas, and Patient Safety Committee.
• Hospital Italiano de Buenos Aires, School of Medicine, Department of Pediatrics, Gascon 450 (1181), Ciudad Autonoma de Buenos Aires, Argentina. paula.otero@hospitalitaliano.org.ar
• Pediatrics. 2008 Sep 1;122(3):e737-43.

ObjectiveThe objective of this study was to assess the prevalence and characteristics of medication errors in pediatric and neonatal inpatients and to measure the impact of interventions to reduce medication errors.MethodsA preintervention and postintervention cross-sectional study was conducted of a sample of prescriptions that were ordered by physicians and medications that were administered by nurses to patients at the NICU, PICU, and general pediatric settings at the Hospital Italiano de Buenos Aires Department of Pediatrics in 2002 and 2004. Number and type of errors, time shift on which they occurred, and whether they had any kind of adverse event on the patient were recorded. Medication errors were stratified according to physicians' and nurses' status. Several interventions, including incorporating a positive safety culture without a punitive management of errors and specific prescribing and drug-administration recommendations were implemented between the 2 phases of the study.ResultsA total of 590 prescriptions and 1174 drug administrations for 95 patients in the first phase of the study and 1144 prescriptions with 1588 drug administrations for 92 patients in the second phase were evaluated. The prevalence of medication error rate in the second phase was 7.3% (199 of 2732) and 11.4% (201 of 1764) in the first phase. The risk difference was -4.1%.ConclusionsThe development of a program mainly centered on the promotion of a cultural change in the approach to medical errors can effectively diminish medication errors in neonates and children.

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