Drug Errors in Hospitalized Children


A new study has found that approximately 1 in 15 children who are hospitalized are harmed by drugs due to mix-ups, overdoses, or adverse reactions.

If you haven’t already read this month’s issue of Pediatrics or otherwise missed the story on MSNBC.com, a new study has found that approximately 1 in 15 children who are hospitalized are harmed by drugs due to mix-ups, overdoses, or adverse reactions. Researchers led by Glenn Takata, MD, who is affiliated with the Patient Safety Program at the Children’s Hospital Los Angeles in California, uncovered this nugget while they were evaluating a new trigger tool/review process they hoped would help detect some of these adverse drug events (ADEs).

Perhaps I’m jaded, but I wouldn’t be surprised if the number of children affected isn’t actually higher. Hospitals are businesses after all, and they are trying to do what everyone else is, ie, doing more with less. Busy staffers just don’t have the time to perform non-specific chart reviews. Plus, who wants to get or give the news that a child has potentially experienced an ADE, especially if it’s due to a mistake?

The review process that the study focused on employed a list of 15 “triggers” that suggest a possible ADE, such as the use of antidotes like naloxone, or the documentation of potential side effects or suspicious lab test results. Used in 12 hospitals, the tool was found to be effective in identifying ADEs, and did so at a rate of 3 times that of the traditional voluntary reporting methods (11.1% vs. 3.7%).

While I’m happy to hear about the success of the trigger tool, I guess I’m astonished that we’re not to the point yet where we can automate this type of review. As someone who spent years in the IT industry, it seems like a no-brainer. I can’t say that I’ve run across a hospital in recent years that uses a manual billing system to collect payment, and yet on the patient care side of business, staffers are struggling with a system that has plainly grown beyond traditional manual processes. I suspect that the number of errors now being reported in hospitals is a symptom of that. I’m aware that the staff at many hospitals enters patient data into systems after patient care has taken place, but there is a time lag involved that isn’t helpful to clinicians. And this task augments what already needs to be done, which means that it piles additional duties on instead of alleviating some of the work.

I guess I’m wondering how far away we are from implementing systems in hospitals that provide software capable of auditing up-to-date patient records for us. Instead of adding better manual processes, is it finally time to employ the technology necessary to support patient care? What it electronic medical records were updated in real time instead of as an afterthought, what would we be able to accomplish in patient care then? In my mind, ADE reporting could then be virtually automatic.

Have you or has anyone you know used trigger tools to catch AEDs, or otherwise dabbled in technology that could solve the problem for hospitals? Share your ideas and experiences here.

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