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SPECIAL ARTICLES:
Donna Woods, Eric Thomas, Jane Holl, Stuart Altman, and Troy Brennan
Adverse Events and Preventable Adverse Events in Children
Pediatrics 2005; 115: 155-160 [Abstract] [Full text] [PDF]
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[Read P3R] Prevention of medical adverse events
Ediriweera B.R., Desapriya, Pike, I., Assistant Professor   (15 March 2005)

Prevention of medical adverse events 15 March 2005
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Ediriweera B.R., Desapriya,
Research Associate-Department of Pediatrics
University of British Columbia -BC-V6H 3V4 Canada,
Pike, I., Assistant Professor

Send letter to journal:
Re: Prevention of medical adverse events

edesap{at}cw.bc.ca Ediriweera B.R., Desapriya, et al.

The Institute of Medicine report “Crossing the quality chasm” identifies patient safety as a prerequisite to high-quality care. (1) Patient safety is receiving growing attention in developed countries in contrast to the less developed countries. We read with interest the study by Wood et al. characterizing pediatric adverse events (PAEs) in selected US hospitals. (2) We applaud the investigators for performing this study and attempting to address the impact of PAEs in institutional practice.

Impact of PAEs in the emergency department (ED) were not evaluated in this study, despite the substantial impact of drug- related ED visits.(3) In a well designed prospective trial, Tafeshi et al. estimated that 28% of all adult ED visits were drug-related of which 70% were deemed preventable.(4) Although we do not know the percentage of PAEs. We appreciate that the PAEs Study attempted to characterize the impact of PAEs in hospitalized children, the omission of a highly acute and heterogeneous patient population in the ED will contribute to underestimation of this problem in US. With the ongoing issues of ED overcrowding and longer wait times in many industrial countries, one can only postulate that the impact of PAEs in the ED may be higher than ever and needs to be further evaluated.

As with any matter of public policy, responding to PAEs requires a mixture of sound empirical evidence, balanced scientific assessment and solid ethical grounding. The great contribution of studies such as Woods and associates' is that, for the first time, we have indisputable facts on pediatric medical adverse events in the US. We also need to evaluate methods of improving our pediatric quality care and safety. However we cannot find any interventions Woods et al; were proposing to minimize the future PAE. This is very important as the theme of their contribution was estimation and prevention of PAEs. What interventions are cost-effective? Which are most easily implemented and likely to have the greatest effect?

From 1983 to 1998, US fatalities from acknowledged prescription errors increased by 242% from 2,876 to 9856. This percentage increase was greater than for almost any other cause of death, and far outpaced the increase in the number of prescriptions.(5)According to a report by the General Accounting Office, errors also occur because of confusion resulting from similarly named drugs. (6) Medication errors are common in the pediatric inpatient setting. About 14.7% of admissions to a neonatal and pediatric intensive care unit involved a medication error. (7) Overall, the hospital wide rate for adverse drug events (ADEs) in a pediatric hospital is estimated to be about 10 %.(8) Adverse drug events are the single leading threat to patient safety. The pediatric population poses a unique set of risks predominantly because of the wide variation in weights.

Teaching trainees the correct way to write a prescription may be beneficial and inexpensive. It is wise to encourage residents to document dose calculations if possible and always include the child's age and weight on the prescription so that a pharmacist can check our math and catch a mistake before it reaches a patient. The number of drugs registered under one generic name should be limited so that drug procurement, regulation, dispensing and prescribing become less complicated and much cheaper, requiring less trained personnel. Infrastructure required for quality assurance of drugs should be strengthened. Quality of the pharmaceuticals should be tested regularly even after introducing drugs to the market. Regularly updated drug information should be freely available to doctors, nurses and pharmacists. Now is the time for all the stakeholders - doctors, government regulatory officials, pharmaceutical companies, pharmacists and consumers to start a dialogue.

Promoting patient safety is a national priority. Health-care providers' own discussions of adverse events can be a good source of data for proactive error prevention. Practice safety relies on a greater safety culture within organizations. But, it also requires the use of "safety tools", largely developed in high-risk industries, that should merit to be adapted, within the world of patient care. Until recently it had been unclear how the skills and tools developed by human factors practitioners in other industries could be applied to medicine. Many of these practices (creating a safety culture; standardizing equipment; simplifying processes; using checklists; improving incident and hazard reporting; handling information better at patient discharge or transfer; improving team communications; managing provider fatigue and shifts; using surgical- site identification protocols) seem likely to be cost-effective in health care, and/or have been shown effective in other industries. (1)

As the investigators clearly outline, this study was just the starting point for understanding the incidence of PAEs and the burden of injury resulting from PAEs in selected US hospitals. Further prospective research is clearly needed to more accurately characterize this problem and provide more accurate estimates on PAEs in all patient care areas of US hospitals. This will better enable us to efficiently establish systems and allocate key resources to reduce PAEs for our children.

Conflict of interest-non declared

References

(1).The Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001.

(2).Woods, D., Thomas, E., Holl, J., Adverse events and preventable adverse events in children. Pediatrics 2005: 115 (1) 155-160

(3). Patel P, Zed PJ. Drug-related visits to the emergency department: how big is the problem? Pharmacotherapy 2002; 22:915-923.

(4). Tafreshi MJ, Melby MJ, Kaback KR, Nord TC. Medication-related visits to the emergency department: a prospective study. Ann. Pharmacother 1999; 33:1252-1257.

(5). Philip, D.P., Bredder, C.C., Morbidity and mortality from medical errors: An increasingly serious public health problem. Annual Rev. Public health 2002: 23; 135-150

(6). GAO report. Adverse drug events: the magnitude of health risk is uncertain because of limited incidence data. GAO/HEHS-00-21 Washington DC: GAO, 2000

(7). Raju T.N.K., Keckes S., Thornton J.P., et al. Medication errors in neonatal and pediatric intensive care units. Lancet. 1989;2: 374-376.

(8). Impicciatore, P., Choonara, I., Clarkson, A., et al., Incidence of adverse drug reactions in paediatric in/out-patients: a systematic review and meta-analysis of prospective studies, Br. J. Clin. Pharmacol. 2001: 52; 77–83.