• Dorothee Niemann, Astrid Bertsche, David Meyrath, Ellen D Koepf, Carolin Traiser, Katja Seebald, Claus P Schmitt, Georg F Hoffmann, Walter E Haefeli, and Thilo Bertsche.
• Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany; Department of Clinical Pharmacy, University of Leipzig, Leipzig, Germany.
• J Clin Nurs. 2015 Jan 1; 24 (1-2): 101-14.

Aims And ObjectivesTo prevent medication errors in drug handling in a paediatric ward.BackgroundOne in five preventable adverse drug events in hospitalised children is caused by medication errors. Errors in drug prescription have been studied frequently, but data regarding drug handling, including drug preparation and administration, are scarce.DesignA three-step intervention study including monitoring procedure was used to detect and prevent medication errors in drug handling.MethodsAfter approval by the ethics committee, pharmacists monitored drug handling by nurses on an 18-bed paediatric ward in a university hospital prior to and following each intervention step. They also conducted a questionnaire survey aimed at identifying knowledge deficits. Each intervention step targeted different causes of errors. The handout mainly addressed knowledge deficits, the training course addressed errors caused by rule violations and slips, and the reference book addressed knowledge-, memory- and rule-based errors.ResultsThe number of patients who were subjected to at least one medication error in drug handling decreased from 38/43 (88%) to 25/51 (49%) following the third intervention, and the overall frequency of errors decreased from 527 errors in 581 processes (91%) to 116/441 (26%). The issue of the handout reduced medication errors caused by knowledge deficits regarding, for instance, the correct 'volume of solvent for IV drugs' from 49-25%.ConclusionPaediatric drug handling is prone to errors. A three-step intervention effectively decreased the high frequency of medication errors by addressing the diversity of their causes.Relevance To Clinical PracticeWorldwide, nurses are in charge of drug handling, which constitutes an error-prone but often-neglected step in drug therapy. Detection and prevention of errors in daily routine is necessary for a safe and effective drug therapy. Our three-step intervention reduced errors and is suitable to be tested in other wards and settings.© 2014 John Wiley & Sons Ltd.

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