MEDICATIONS: STUDY DOCUMENTS MEDICATION ERRORS AMONG HOSPITALIZED CHILDREN

Most Potential Adverse Drug Events Are Preventable

April 25, 2001 — Errors involving medication for hospitalized children are relatively common, and further efforts are needed to reduce them, according to an article in the April 25, 2001, issue of The Journal of the American Medical Association.

Rainu Kaushal, M.D., M.P.H., of Children's Hospital, Boston, studied data from 1,120 patients admitted to two urban teaching hospitals during six weeks in April and May of 1999. The authors assessed the rates of medication errors, adverse drug events (ADEs), and potential ADEs, compared pediatric rates with previously reported adult rates, analyzed the major types of errors, and evaluated the potential impact of prevention strategies.

According to background information cited in the article, few epidemiological data are available regarding medication errors in the pediatric inpatient setting. For this study, medication errors, potential ADEs and ADEs were identified by clinical staff reports and review of medication order sheets, medication administration records and patient charts.

"We reviewed 10,778 medication orders and found 616 medication errors (5.7 percent), 115 potential ADEs (1.1 percent), and 26 ADEs (0.24 percent)," the authors write. "Of the 26 ADEs, 5 (19 percent) were preventable."

"While the preventable ADE rate was similar to that of a previous adult hospital study, the potential ADE rate was three times higher," they continue. "The rate of potential ADEs was significantly higher in neonates in the neonatal intensive care unit (NICU)."

The authors were not surprised that errors with potential for harm occurred most often in the youngest, most vulnerable patients cared for in the NICU. "Neonatal weights change rapidly, making appropriate dosing particularly difficult," they write. "Moreover, medication errors in critically ill neonates may have more serious consequences compared with relatively healthy neonates or older children because they have limited ability to buffer errors. Pharmacists also face special challenges with neonatal drugs because medications generally are not supplied in dosages suitable for neonates and must be diluted."

Physician reviewers concluded that more than nine out of 10 potential ADEs might have been prevented. "Most potential ADEs occurred at the stage of drug ordering (79 percent) and involved incorrect dosing (34 percent), anti-infective drugs (28 percent), and intravenous medications (54 percent)," the authors write. "Physician reviewers judged that computerized physician order entry could potentially have prevented 93 percent and ward-based clinical pharmacists 94 percent of potential ADEs."

The authors assert that the high risk of medication errors highlights the importance of developing, testing, and implementing effective error-prevention strategies in pediatrics. "Human fallibility is magnified substantially by complex and poorly designed systems, poor teamwork, and psychological and environmental stressors such as fatigue, anxiety, poor lighting, and noise," they write. "The safest work environments address these issues by designing systems to prevent errors, make errors visible, and mitigate the effects of errors."

"The development and testing of medication error reduction interventions is important in pediatrics, especially in the NICU, given the increased medical vulnerability and decreased communication ability of small and critically ill children, the need for weight-based dosing, and the need for pharmacy dilution of stock medications," they conclude. "To reduce the rates of potential and preventable ADEs in pediatrics, the most effective interventions are likely to be computerized physician order entry with integrated clinical decision support and full-time, ward-based clinical pharmacists."

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