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Pain Res Manag. 2011 Mar-Apr;16(2):93-8.

Opioid medication errors in pediatric practice: four years' experience of voluntary safety reporting.

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Department of Anesthesia & Pain Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario.



Opioids are the most common source of drug error that leads to harm in pediatric hospitals.


To undertake a comprehensive review of experience with voluntary safety reports describing pediatric opioid medication errors at The Hospital for Sick Children (Toronto, Ontario), and to characterize the specific opioids involved, severity and type of error described, hospital location and time of day that the error occurred.


All medication-related safety reports submitted to an anonymous, voluntary electronic safety reporting database in a university-affiliated pediatric hospital during the first four years of its use were examined. A database of opioid error reports was created for further analysis.


A total of 5,935 medication-related safety reports were collected, 507 of which described opioids. Morphine was the most frequently reported opioid, administration was the most frequently reported stage of the medication process (192 errors) and surgical wards were the location from which opioid error was most frequently reported (128 reports). Twenty-two reports described patient harm requiring urgent treatment and intervention. Errors with codeine or hydromorphone resulted in the most significant harm reported. A total of 162 reports described problems with inappropriate opioid disposal, missing opioids, or incorrect opioid counts and checks.


Future opportunities for improvement in opioid safety should focus on morphine, opioid administration errors in general, the safe disposal of opioids in the hospital environment and the identification of pain as an adverse event.

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