1. Section Editor(s): STOKOWSKI, LAURA A. RN, MS

Article Content

The most recent sentinel event alert issued by the Joint Commission aims to reduce the harm to infants and children that can result from medication errors.1


In a recent study, Takata and colleagues2 used a trigger tool to identify adverse events in 12 children's hospitals across the United States. Findings revealed an adverse drug event (ADE) rate of 11.1% in pediatric patients, a rate much higher than suggested by previous research. Only 3.7% of the ADEs were identified in hospital-based occurrence reports.2 Furthermore, 22% of the ADEs were considered preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively.2


Owing to the greater vulnerability of infants and children to medication errors and resulting harm, the Joint Commission in it its sentinel event alert, Preventing Pediatric Medication Errors, outlined more than 20 pediatric-specific strategies for reducing medication errors.1 Among its recommended actions, the Joint Commission addresses standardization of medications and administration techniques, pharmacy oversight of the medication administration process, and judicious use of technology, such as bar coding, smart pumps, and automated dispensing systems. Education for those who administer medications to children (parents and healthcare providers) is emphasized. Hospital staff should have ready Web site access to up-do-date, pediatric-specific information about medications. Should a serious error or an ADE occur, the organization should conduct a root-cause analysis and develop and implement a corrective action plan that should be monitored for effectiveness. Transparency and disclosure about errors, with both staff and families, is encouraged.1


For the complete list of Joint Commission's recommendations, see Sentinel Event Alert. Issue 39, April 11, 2008




1. The Joint Commission. Preventing pediatric medication errors. Sentinel Event Alert. Issue 39. Published April 11, 2008. Accessed May 9, 2008. [Context Link]


2. Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics. 2008;121:e927-e935. [Context Link]