Medical
Errors Are Kids' Stuff
Mistakes made in 1 of 16 medication orders
By Edward Edelson
TUESDAY, April 24 (HealthScout) -- Boston Children's
Hospital and Massachusetts Hospital for Children
are two of the country's best hospitals for young
patients. But a study finds that mistakes were
made in one of every 16 drugs prescribed for 1,120
children treated in those hospitals during a six-week
period in 1999.
"We reviewed 10,778 medication orders and
found 616 medication errors (5.7 percent), 115
potential adverse drug reactions (1.1 percent)
and 26 adverse drug reactions," says a report
in this week's Journal of the American Medical
Association.
That error rate is about the same as has been
reported in studies of adult patients, says Dr.
Rainu Kaushal. She is an instructor in medicine
at Harvard Medical School and led the group of
researchers. And while none of the mistakes were
fatal, "there are a number of close calls
or near misses," she says.
The study is important because "this is the
first to delve into the issue of pediatric medication
errors," says Dr. Gregg S. Meyer, director
of the Center for Quality Improvement and Patient
Safety at the federal Agency for Healthcare Research
and Quality, which helped fund the study.
"The trend thus far is that wherever we have
looked for medical errors, we have found them,"
Meyer says. "The findings documented for
adults now are mirrored by the findings for pediatric
care."
A report by the Institute of Medicine last year
estimated that medication errors cause 7,000 hospital
deaths a year. Some experts say the number could
be higher.
Breaking the results down by category, the Boston
researchers found that most of the errors occurred
at the stage when a drug was ordered by a physician.
Many of those errors were mistakes in the dosage
ordered for the young patient, because drug dosages
often are based on the weight of the patient and
a child can gain weight quickly. In addition,
"pharmacists have to dilute solutions, which
are often at adult strengths, and they must divide
pills for a young patient," Kaushal says.
Another source of error is understandable, she says:
"Children, particularly those who are small
and critically ill, cannot communicate well."
The good news is that more than 90 percent of the
errors were potentially preventable, and that the
hospitals are instituting programs to prevent them,
she says. One program is having computerized systems
in which doctors enter medication orders. Another
is having clinical pharmacists in each ward.
"Physician reviewers judged that computerized
physician order entry could potentially have prevented
93 percent and ward-based clinical pharmacists 94
percent of potential adverse drug reactions,"
the report says.
Other measures include bar-coding medications, with
the bar code on the drug matching that worn by the
patient; having robotic help in preparing medications;
and an automated alert system that would signal
when a patient needs a drug and the proper dosage
for the patient, Kaushal says.
"In both these hospitals, we have been very
active in planning ways to make the hospital more
safe for the patients," she says. "We
are investing in computerized systems, ward-based
pharmacists and computerized transcribing."
Meyer says the message of the study is that safety
lies "in looking at the entire chain, beginning
with the physician ordering the medication to the
pharmacist filling the order to the delivery of
the medication to the patient. Each step is fraught
with potential hazard. The real issue is not to
look at any individual step, but to look at the
entire system and where the opportunities for improvement
in providing safe care lie."
Another innovation being studied is the use of "smart"
intravenous delivery systems, programmed to deliver
the correct dose of an intravenous solution. Something
as basic as increased staffing and closer coordination
between doctors and nurses can also reduce errors,
Kaushal says.
What
to do
Parents have a role to play in protecting their
children, Kaushal says. "Parents can help by
bringing in adequate lists of medications, or the
medications themselves," she says. "They
can help by asking questions about medications,
if they don't understand why the child is taking
a medication. It should be a partnership with the
health-care providers."
For more information on medical errors and how to
prevent them from happening to you, check out theAgency
for Healthcare Research and Qualityandhere is the
report to the president on medical errors from the
Quality in the Health Care Industry task force.
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