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Children pose unique challenges to the medication use system. For example, almost all pediatric drug doses must be calculated. Clinicians care for the tiniest premature babies, toddlers, school age children, teenagers, and sometimes even adults in the pediatric inpatient setting. Pharmacists must often dilute stock solutions or divide pills. Young children are less able to communicate side effects. Finally, all children, but most particularly young, small, sick children, are less able to physiologically tolerate a medication error.

The study used data collected at Children's Hospital Boston and MassGeneral Hospital for Children from medical and surgical units, pediatric intensive care units, and a neonatal intensive care unit. A multidisciplinary team, led by Children's Hospital medicine/pediatric physician Rainu Kaushal, MD, MPH, identified incidents by soliciting reports from house staff, nurses, and pharmacists and from daily medication order sheet, medication administration record, and chart review. Incidents were classified as medication errors, potential adverse drug events, or adverse drug events (ADEs). The incidents were rated on severity and attribution (whether the event was caused by the drug) by two independent reviewers.

''Our study found that only a small subset of the serious medication errors actually reached patients,'' says Kaushal. ''And of those that did indeed reach patients during the study period, none were life threatening. Nevertheless, an important next step, which we are presently undertaking at Children's and the MGH, is an effort to reduce the numbers of serious medication errors using a system-based approach. Also important are further studies to better document the extent and severity of the problem, particularly in community-based hospitals were most children receive inpatient care.''

Of 10,778 orders reviewed, 616 or 5.7 percent were identified as medication errors; 115 as potential ADEs (1.1 percent); and 26 as ADEs (.24 percent). Of the ADEs, 5 were preventable. Medication errors are errors in drug ordering, transcribing, dispensing, administering or monitoring. Some medication errors, referred to as potential ADEs, have the potential for injuring the patient. Potential ADEs are either intercepted before reaching the patient or not intercepted. An example of an intercepted potential ADE is a pharmacist intercepting an order for penicillin in a penicillin- allergic patient. Adverse drug events are injuries that result from the use of a drug. Some of these are associated with a medication error and therefore judged to be preventable, while some are unassociated with a medication error and therefore judged to be non-preventable. For example, a preventable ADE would be the development of rash after the administration of penicillin to a known penicillin-allergic patient. In contrast, an example of a non-preventable ADE is the development of a rash after the administration of penicillin in a patient without a documented allergy to penicillin.

Since the time of the study, Children's Hospital Boston has added full-time, patient unit-based clinical pharmacists to its multidisciplinary and cardiac intensive care units and hematology/oncology units, and added part-time, patient unit-based clinical pharmacists to its general pediatrics units and neonatal intensive care unit. In March 2001, Children's launched a computerized chemotherapy order entry system. This system, or a similar one, will ultimately be implemented hospital-wide. Children's has pre-printed medication order sets for its clinical practice guidelines, as well as for antibiotics not covered in the CPGs. The hospital has also implemented an electronic medication administration recording flow sheet system in the intensive care units. At MassGeneral Hospital for Children, a computerized physician order entry system will be implemented this year. All floors have unit-based clinical pharmacists, and a standardized unit based medication dosing system and implementation of ''smart'' intravenous delivery pumps are under discussion.

In addition to Kaushal, other members of the study group included David W. Bates, MD, (Brigham and Women's Hospital), Christopher Landrigan, MD, MPH, (Children's Hospital), Frank Federico RPh, (Risk Management Foundation), Margaret Clapp, RPh, (Massachusetts General Hospital), Kathryn McKenna, MS, RN, (Children's Hospital) and Donald Goldmann, MD, (Children's Hospital). The study was supported by the Harvard Risk Management Foundation. Kaushal was supported by a training grant from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

The Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $300 million and major research centers in AIDS, the neurosciences, cardiovascular research, cancer, cutaneous biology, transplantation biology and photo-medicine.