Michiel Bergmans - Preventing medication errors on a paediatric intensive care unit

afstudeercolloquium

A substantial part of all medical errors involves medication. Although it is impossible to eliminate all potential errors, the environment of hospital staff can be altered to induce error prevention and stimulate recovery from errors. One way to prevent medication errors is the use of computerised prescriber order entry (CPOE). CPOE facilitates prescription of medication; one of the most error-prone stages of the medication process. The aim of the present study, requested by the paediatric intensive care unit (PICU) of the University Medical Centre Groningen, was to analyse and improve the medication process and the CPOE-system used at the PICU, in order to prevent medication errors. First, a Hierarchical Task Analysis (HTA) was conducted to create a thorough understanding of the medication process. A follow-up analysis was carried out to identify potential errors. Possible solutions were proposed in order to eliminate several of these hazards.