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PEDIATRICS Vol. 111 No. 4 April 2003, pp. 722-729

Prioritizing Strategies for Preventing Medication Errors and Adverse Drug Events in Pediatric Inpatients

Elizabeth B. Fortescue, MD*, Rainu Kaushal, MD, MPH*,{ddagger}, Christopher P. Landrigan, MD, MPH*, Kathryn J. McKenna, MS, RN*, Margaret D. Clapp, RPh§, Frank Federico, RPh||, Donald A. Goldmann, MD* and David W. Bates, MD, MSc{ddagger}

* Departments of Medicine, Quality Improvement, and Risk Management, Children’s Hospital, Boston, Massachusetts
{ddagger} Division of General Internal Medicine, Brigham and Women’s Hospital, Partners HealthCare Systems, and Harvard Medical School, Boston, Massachusetts
§ Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts
|| Risk Management Foundation, Cambridge, Massachusetts

--> Objectives. Medication errors in pediatric inpatients occur at similar rates as in adults but have 3 times the potential to cause harm. Error prevention strategies in this setting remain largely untested. The objective of this study was to classify the major types of medication errors in pediatric inpatients and to determine which strategies might most effectively prevent them.

Methods. A prospective cohort study was conducted of 1020 patients who were admitted to 2 academic medical centers during a 6-week period in April and May 1999. Medication errors were characterized by subtype. Physician raters evaluated error prevention strategies and identified those that might be most effective in preventing errors.

Results. Of 10 778 medication orders reviewed, 616 contained errors. Of these, 120 (19.5%) were classified as potentially harmful, including 115 potential adverse drug events (18.7%) and 5 preventable adverse drug events (0.8%). Most errors occurred at the ordering stage (74%) and involved errors in dosing (28%), route (18%), or frequency (9%). Three interventions might have prevented most potentially harmful errors: 1) computerized physician order entry with clinical decision support systems (76%); 2) ward-based clinical pharmacists (81%); and 3) improved communication among physicians, nurses, and pharmacists (86%). Interrater reliability of error prevention strategy assignment was good (agreement: 0.92; {kappa}: 0.82).

Conclusions. Of the assessed interventions, computerized physician order entry with clinical decision support systems; ward-based clinical pharmacists; and improved communication among physicians, nurses, and pharmacists had the greatest potential to reduce medication errors in pediatric inpatients. Development, implementation, and assessment of such interventions in the pediatric inpatient setting are needed.

Key Words: medication error • prevention strategy • pediatric inpatient

Abbreviations: ADE, adverse drug event • ICU, intensive care unit • CPOE, computerized physician order entry • MAR, medication administration record • CDSS, clinical decision support system

Received for publication Mar 21, 2002; Accepted Sep 27, 2002.




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