1. Potera, Carol


Minimizing distractions during drug delivery is one strategy.


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Hospitalized children experience adverse drug events three times more often than adults, and as many as 35% of such events are serious or life threatening. Pediatric medication errors are also expensive, costing hospitals $2,000 to $8,750 per case. But now a new program designed to standardize medication ordering, dispensing, and administration at 13 freestanding children's hospitals has reduced the overall rate of pediatric medication errors there by 42%.

Figure. The conseque... - Click to enlarge in new windowFigure. The consequences of adverse drug events can have a devastating effect on nurses. Kimberly Hiatt, a longtime critical care nurse at Seattle Children's Hospital, committed suicide in April 2007, seven months after accidentally overdosing an infant with severe heart problems who later died. Photo courtesy of the Hiatt family and

An interdisciplinary advisory panel developed a "change package" of interventions that targeted the entire medication delivery system to prevent adverse drug events in children. The hospitals each chose interventions to implement from among those in the package (no hospital tried them all). There were five categories of interventions: standardizing medication ordering, employing reliable medication-dispensing processes, improving medication-administration processes, improving the patient safety culture, and enhancing clinical decision support. The interventions were performed by multidisciplinary teams within each facility and could include nurses, physicians, pharmacists, quality professionals, clinical educators, information technology staff, and accreditation and risk-management personnel.


The study focused on four high-risk medication types or routes-opioids, anticoagulants, insulin, and total parenteral nutrition-dispensed on all inpatient units and in all EDs. Adverse drug event rates after 12 months were compared with those in the three-month baseline period. The overall rate declined by 42%, although the rate of opioid-related events fell by 51% and other medication errors declined by 41%. Several hospitals decreased their overall adverse drug event rates by more than 50%. The researchers estimated that 5,843 errors were prevented during the 12-month study.


Nurses in particular led the way in minimizing distractions and interruptions during medication administration. One strategy was to use caution tape or signs to warn others that they were giving medications. Such visual cues "trigger an awareness among coworkers during medication administration to minimize nonurgent distractions and interruptions," said study coauthor Cindy McConnell, ambulatory nursing director at Children's Hospital Colorado in Aurora.


"Not only do nurses provide leadership in the reduction of adverse drug events," added lead author Eric Tham, an assistant professor of pediatrics at the University of Colorado School of Medicine, also in Aurora, "but they also provide the important last line of defense in preventing them."-Carol Potera




Tham E, et al. Pediatrics 2011;128(2):e438-e445. Epub 2011 Jul 4.