This past week, Dr. Kim Sears from Queen’s School of Nursing, along with her colleagues from across Canada, O’Brien-Pallas, Stevens, and Murphy, published their findings on a Pan-Canadian study of medication errors in the paediatric hospital population. The results were published in the Journal of Pediatric Nursing1, and reported in this week’s National Post by reporter Tom Blackwell.2
Dr. Sears is an Assistant Professor in the School of Nursing, Co-Director of our new Master of Science in Healthcare Quality, and Deputy Director/Patient Safety, Queen’s Joanna Briggs Collaboration.
Dr. Sears’ study revealed some alarming statistics. In a small sample of 18 hospital wards, she uncovered four deaths attributable to medication error. Over the three-month period of the study, which involved a questionnaire in which nursing staff reported medication errors or “near misses”, there were 372 errors or potential errors uncovered. “As well as the four deaths, 51 were graded as potentially lethal, 20 as serious, 112 as significant and 185 minimal.”2
The finding of systematic medication-related errors in hospitals is of course, not new. The Institute of Medicine in the United States, shone a light on this problem with the seminal publication, To Err is Human.4 This landmark work reported that there were between 44,000 and 98,000 deaths in U.S. hospitals that are attributable to medication errors. There have been literally thousands of studies since, and more importantly, a systematic movement around the world, to minimize and mitigate medical error. Still, fourteen years later, Sears’ publication illustrates just how difficult this is, and underscores the fact that we still need to be vigilant and attentive to medical error with virtually everything we, as health professional clinicians, do.
If you have any comments on patient safety issues in general, or medication errors in specific, please respond to this blog, or better yet…please drop by the Macklem House, my door is always open.
1. Sears K, O’Brien-Pallas L, Stevens B, Murphy GT. The Relationship Between the Nursing Work Environment and the Occurrence of Reported Paediatric Medication Administration Errors: A Pan Canadian Study. J of Pediatric Nursing. Published on line, 04 January 2013.
2. Tom Blackwell, National Post, http://news.nationalpost.com/2013/01/11/thats-four-children-who-died-hospital-drug-errors-blamed-for-child-deaths-in-new-report/