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.
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