Pediatric antidepressant medication errors in a national error reporting database

Michael L. Rinke, David G. Bundy, Andrew D. Shore, Elizabeth Ann Colantuoni, Laura Morlock, Marlene R. Miller

Research output: Contribution to journalArticle

Abstract

Objective: To describe inpatient and outpatient pediatric antidepressant medication errors. Methods: We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years. Results: Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p <.001) and more errors due to inaccurate or omitted transcription (p <.001), compared with inpatient errors. Family notification of medication errors was reported in only 12% of errors. Conclusions: Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.

Original languageEnglish (US)
Pages (from-to)129-136
Number of pages8
JournalJournal of Developmental and Behavioral Pediatrics
Volume31
Issue number2
DOIs
StatePublished - Feb 2010

Fingerprint

Medication Errors
Antidepressive Agents
Databases
Pediatrics
Inpatients
Truth Disclosure
Outpatients
Trazodone
Patient Harm
Off-Label Use
Bupropion
Sertraline
Pharmacopoeias
Fluoxetine
Education
Research
Therapeutics

Keywords

  • Antidepressant
  • Medication error
  • MEDMARX
  • Pediatric
  • Psychiatry

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Developmental and Educational Psychology
  • Psychiatry and Mental health

Cite this

Pediatric antidepressant medication errors in a national error reporting database. / Rinke, Michael L.; Bundy, David G.; Shore, Andrew D.; Colantuoni, Elizabeth Ann; Morlock, Laura; Miller, Marlene R.

In: Journal of Developmental and Behavioral Pediatrics, Vol. 31, No. 2, 02.2010, p. 129-136.

Research output: Contribution to journalArticle

Rinke, Michael L. ; Bundy, David G. ; Shore, Andrew D. ; Colantuoni, Elizabeth Ann ; Morlock, Laura ; Miller, Marlene R. / Pediatric antidepressant medication errors in a national error reporting database. In: Journal of Developmental and Behavioral Pediatrics. 2010 ; Vol. 31, No. 2. pp. 129-136.
@article{2260219ea5824b95ad5f3cfe8e9003f2,
title = "Pediatric antidepressant medication errors in a national error reporting database",
abstract = "Objective: To describe inpatient and outpatient pediatric antidepressant medication errors. Methods: We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years. Results: Of the 451 error reports identified, 95{\%} reached the patient, 6.4{\%} reached the patient and necessitated increased monitoring and/or treatment, and 77{\%} involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30{\%} cited dispensing, 28{\%} cited transcribing, and 7.9{\%} cited prescribing. The most commonly cited medications were sertraline (20{\%}), bupropion (19{\%}), fluoxetine (15{\%}), and trazodone (11{\%}). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59{\%} vs 32{\%}, p = .023), errors occurring in inpatient care (93{\%} vs 68{\%}, p = .012) and extra doses of medication (31{\%} vs 10{\%}, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p <.001) and more errors due to inaccurate or omitted transcription (p <.001), compared with inpatient errors. Family notification of medication errors was reported in only 12{\%} of errors. Conclusions: Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.",
keywords = "Antidepressant, Medication error, MEDMARX, Pediatric, Psychiatry",
author = "Rinke, {Michael L.} and Bundy, {David G.} and Shore, {Andrew D.} and Colantuoni, {Elizabeth Ann} and Laura Morlock and Miller, {Marlene R.}",
year = "2010",
month = "2",
doi = "10.1097/DBP.0b013e3181ce6509",
language = "English (US)",
volume = "31",
pages = "129--136",
journal = "Journal of Developmental and Behavioral Pediatrics",
issn = "0196-206X",
publisher = "Lippincott Williams and Wilkins",
number = "2",

}

TY - JOUR

T1 - Pediatric antidepressant medication errors in a national error reporting database

AU - Rinke, Michael L.

AU - Bundy, David G.

AU - Shore, Andrew D.

AU - Colantuoni, Elizabeth Ann

AU - Morlock, Laura

AU - Miller, Marlene R.

PY - 2010/2

Y1 - 2010/2

N2 - Objective: To describe inpatient and outpatient pediatric antidepressant medication errors. Methods: We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years. Results: Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p <.001) and more errors due to inaccurate or omitted transcription (p <.001), compared with inpatient errors. Family notification of medication errors was reported in only 12% of errors. Conclusions: Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.

AB - Objective: To describe inpatient and outpatient pediatric antidepressant medication errors. Methods: We analyzed all error reports from the United States Pharmacopeia MEDMARX database, from 2003 to 2006, involving antidepressant medications and patients younger than 18 years. Results: Of the 451 error reports identified, 95% reached the patient, 6.4% reached the patient and necessitated increased monitoring and/or treatment, and 77% involved medications being used off label. Thirty-three percent of errors cited administering as the macrolevel cause of the error, 30% cited dispensing, 28% cited transcribing, and 7.9% cited prescribing. The most commonly cited medications were sertraline (20%), bupropion (19%), fluoxetine (15%), and trazodone (11%). We found no statistically significant association between medication and reported patient harm; harmful errors involved significantly more administering errors (59% vs 32%, p = .023), errors occurring in inpatient care (93% vs 68%, p = .012) and extra doses of medication (31% vs 10%, p = .025) compared with nonharmful errors. Outpatient errors involved significantly more dispensing errors (p <.001) and more errors due to inaccurate or omitted transcription (p <.001), compared with inpatient errors. Family notification of medication errors was reported in only 12% of errors. Conclusions: Pediatric antidepressant errors often reach patients, frequently involve off-label use of medications, and occur with varying severity and type depending on location and type of medication prescribed. Education and research should be directed toward prompt medication error disclosure and targeted error reduction strategies for specific medication types and settings.

KW - Antidepressant

KW - Medication error

KW - MEDMARX

KW - Pediatric

KW - Psychiatry

UR - http://www.scopus.com/inward/record.url?scp=76849107321&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=76849107321&partnerID=8YFLogxK

U2 - 10.1097/DBP.0b013e3181ce6509

DO - 10.1097/DBP.0b013e3181ce6509

M3 - Article

C2 - 20110823

AN - SCOPUS:76849107321

VL - 31

SP - 129

EP - 136

JO - Journal of Developmental and Behavioral Pediatrics

JF - Journal of Developmental and Behavioral Pediatrics

SN - 0196-206X

IS - 2

ER -