National collaborative: Top five drugs reported as causing harm through medication error in pediatrics.

The Canadian Association of Paediatric Health Centres (CAPHC) and the Institute for Safe Medication Practices Canada (ISMP Canada) are working collaboratively to enhance the safety of pediatric medication use. Eleven CAPHC member organizations submitted data on more than 4,000 medication incidents to ISMP Canada for the period October 2005 to June 2008, 305 of which were reported as resulting in harm. From this, the top five drugs causing harm through medication error and contributing factors to the incidents were identified. In this article, we intend to inform critical care practitioners of the medication incident analyses and the collaborative pediatric patient safety initiatives underway. The Canadian Association of Paediatric Health Centres (CAPHC) and the Institute for Safe Medication Practices Canada (ISMPCanada) are working collaboratively to enhance the safety of pediatric medication use. The treatment of acutely ill infants, children and youth presents unique challenges in the realm of medication safety. A variety of factors, including the age, size, and physiological status of these patients, can increase the likelihood that medication incidents 1 , particularly those involving high-alert medications 2 , will result in harm (Levine et al., 2001). This collaborative project, guided by a national advisory committee of content experts, practitioners, and researchers is being undertaken in two phases. In this article we share, with permission, information from an ISMP Canada Safety Bulletin highlighting an overview of phase one, which includes the top five medications most frequently involved in errors reported as causing harm in pediatric patients, and some of the contributing factors (ISMP Canada, 2009).