Errors in Medication Orders and the Nursing Staff's Reports in Medical Notes of Children|
Valizadeh, Fatemeh; Ghasemi, Syedeh-Fatemeh; Najafi, Seyed-Saeid; Delfan, Bahram & Mohsenzadeh, Azam
Medication errors are the most common type of medical error and an avoidable cause of
iatrogenic injury in pediatric patients. These errors can occur at any point in the process of ordering,
transcribing, dispensing, administering, or monitoring medications. This study was conducted to verify
medication errors by analyzing medication orders and the nursing staff's reports in medical notes of
children admitted in Madany Pediatric Hospital, Khoramabad, Iran, in the first 6 months of 2004.
This is a descriptive cross-sectional and hospital information based study. Samples included
898 medical charts of children selected by random sampling. The data collection instruments were a
demographic questionnaire for patients, physicians and nurses, a scale for analyzing medication orders
and a scale for analyzing the nursing staff's reports. Data are analyzed by SPSS Ver.11.5 software.
Analysis of the medication orders indicated that in 74.1%, drug administration precautions
were not written down, in 47.8%, exact time or intervals of drug administration were not recorded, in
45.5%, drug unit was not stated or it was incomplete or ambiguous, and in 20.5%, orders had at least
one drug interaction. Analysis of nursing staff's reports indicated that in 77.5%, drug administration
precautions were not indicated, in 14.9%, drug interactions were not noted, in 14.8%, time or intervals
of drug administration were not according to orders, and in 6.3%, medication was not administered by
In the busy and complex environment of pediatric units, medication errors can occur
frequently. However, most of these errors are trivial and do not harm patients. The types of errors
indicate the need for continuous education and the implementation of management tools that allow the
promotion of the practice and monitoring results as medication errors are indicators of the quality of the
healthcare provided. Therefore, their detection and systematic analysis of their causes can contribute to
their systematic prevention, thus improving the healthcare.
Medication error; Medication order; Nursing staff's report; Drug order; Drug interaction