Study finds child medication errors 5X more common

- By Krista Conger

Review of hospitalized children's records used new method to detect adverse drug events

Hospitalized children experience medication-related harm nearly five times more frequently than previously believed, according to a new study led by a researcher at Lucile Packard Children's Hospital and the School of Medicine.

The researchers used a 'trigger tool' method, scrutinizing medical charts to ferret out previously unidentified episodes of harm, or adverse drug events.

'A trigger is basically a red flag that a harmful event may have occurred,' said senior author Paul Sharek, MD, MPH, chief clinical patient safety officer at Packard Children's and assistant professor of pediatrics at the medical school. 'When we identify a trigger, we take a closer look at the events surrounding it in that patient's chart.'

The study is the first large-scale, national investigation using this method of chart review to examine patterns of medication-related harm in hospitalized children. Previous efforts to identify the frequency of adverse drug events in pediatric institutions relied mostly on either comprehensive, unfocused reviews of randomly selected medical records, administrative databases or voluntary reporting methods.

Targeted, or triggered, chart review is somewhat like scanning a page of text for a person's name. Rather than reading every word, most people skim for give-away indications, like capital letters within a sentence, to help them zero in on their target. Triggers for adverse drug events included the use of antidotes to combat dosing errors, severely abnormal laboratory test results or the sudden cessation of drug treatment.

Although medication errors can lead to adverse drug events, the two are not identical. A child can experience an adverse side event like a rash even when appropriately medicated. Identifying these occurrences, however, can help pinpoint those that are particularly prevalent or troublesome and focus future efforts on preventing them. For example, Packard Children's has since instituted evidence-based medication order sets using 'corollary orders,' in which a drug like a stool softener or anti-emetic is automatically prescribed when children are started on medications likely to cause side effects like constipation or nausea.

The researchers performed targeted chart review on 960 charts from 12 children's hospitals across the country. They found 107 unique adverse drug events, or 11.1 per 100 patients and 15.7 per 1,000 patient days. Previous studies had estimated a frequency of about 2.3 per 100 patients. Fewer than 4 percent of these harmful events had been detected by hospital incidence reports. Adverse drug events were most commonly associated with the use of analgesics, opioids or antibiotics. The most common events included itching and nausea, although some were more serious. The overwhelming majority, or 97 percent of the adverse drug events, resulted only in temporary, mild harm.

Although the study was published in the April issue of Pediatrics, the data were first gathered and analyzed in 2002. The interval allowed Packard Children's and other participating hospitals time to craft specific interventions to address their individual weak spots. For example, in 2003 Packard Children's instituted preprinted orders - a kind of medication menu for doctors that reduces errors by providing standardized doses and eliminating sloppy writing, unclear abbreviations and potentially confusing brand names. More recently, the hospital has begun implementing computerized provider order entry, which automatically flags dosage errors and dangerous drug interactions as soon as medications are ordered.

Packard Children's has won national recognition for its success in reducing adverse drug events, in part stemming from the knowledge obtained from using the trigger tool methodology locally. In 2005, the hospital received the 2005 Race for Results Award from the Child Health Corp. of America. The hospital won the award - the fourth in a 12-month period for ongoing improvements in patient safety - for significantly reducing the already low number of adverse drug events at the hospital over the previous two years.

'We wanted to understand and establish the epidemiology of harm,' said Sharek, 'to determine what our biggest medication safety issues are. In the future, we will explore ways to identify harmful events in real time and even to predict and prevent them.'

Sharek's co-authors include colleagues from the University of Southern California School of Medicine, Children's Hospital Los Angeles, and the Child Health Corp. of America.

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu.

2023 ISSUE 3

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