Published online October 2, 2006
PEDIATRICS Vol. 118 No. 4 October 2006, pp. e1124-e1129 (doi:10.1542/peds.2005-3183)
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ARTICLE

Risk Reduction for Adverse Drug Events Through Sequential Implementation of Patient Safety Initiatives in a Children's Hospital

Michael S. Leonard, MD, MSa,b, Michael Cimino, RPh, MSa,c, Steven Shaha, PhD, DBAa, Sandra McDougal, RN, MSNa, Joanne Pilliod, RNa and Linda Brodsky, MDa,d

a Center for Pediatric Quality, Women and Children's Hospital of Buffalo, Buffalo, New York
b Departments of Pediatrics
d Otolaryngology, School of Medicine and Biomedical Sciences
c School of Pharmacy and Pharmaceutical Sciences, State University of New York at Buffalo, Buffalo, New York

BACKGROUND. Medication management is a complex, multifaceted system. Prescribing errors occur upstream in the process, and as such, their effects can be perpetuated, and sometimes even exacerbated, in subsequent steps. These errors place patients at risk of adverse drug events. Children, especially young infants, are at particular risk because of their size, unique physiology, and immature ability to metabolize drugs.

OBJECTIVE. The purpose of this study was to reduce the risk of harm to children resulting from prescribing errors.

METHODS. We sequentially implemented patient safety initiatives over a 1-year time frame at a pediatric tertiary care academic facility. The initiatives included an educational Web site with competency examination, distribution of a personal digital assistant-based standardized dosing reference, a zero-tolerance policy for incomplete or incorrect medication orders, prescriber performance feedback, and presentation of outcome data at citywide grand rounds. A total of 8718 orders were collected and analyzed to assess the impact of these initiatives.

RESULTS. The absolute risk reduction from prescribing errors was 38 per 100 orders, with a relative risk reduction of 49%. Web-based education with point-of-care drug references and a zero-tolerance policy for incomplete or incorrect orders were most effective in decreasing potential adverse drug events. Documentation of appropriate weight-based dosing and indication for therapy increased by 24% and 42%, respectively.

CONCLUSIONS. Process-improvement initiatives focusing on prescriber education and behavior modification can reduce the risk of harm to pediatric patients from prescribing errors.

Key Words: patient safety • medication errors • adverse events • risk reduction • pediatric

Abbreviations: ADE—adverse drug event • CPOE—computerized physician order entry • FFF—forced-format form • WCHOB—Women and Children's Hospital of Buffalo • pADE—potential adverse drug event • CHECKS—Children's Hospital Ensuring Comfort and Kids Safety • PDA—personal digital assistant • ICD-9—International Classification of Diseases, Ninth Revision

Accepted Apr 26, 2006.


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