Joint Commission focuses on pediatric drug errors
Many errors 'don't ever reach the light of day'
Medication errors harm roughly one out of 15 hospitalized children, according to a new study. Researchers reported an 11.1% rate of adverse drug events in pediatric patients. Of those, 22% were deemed preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively.1
The Joint Commission has issued a Sentinel Event Alert with recommendations to prevent pediatric medication errors. There wasn't one specific event that led to the alert being issued, according to Peter Angood, MD, The Joint Commission's vice president and chief patient safety officer.
"We consider medication safety in general to be one of our high-priority focus areas. We recognized that the awareness in pediatric patients wasn't there to the same level as it is for adult patients. So we brought the alert forward to draw attention to the importance of this issue," says Angood.
Although the recommendations in the alert aren't part of the survey process, The Joint Commission's standards are currently being revised, including its medication management standards.
"We are making efforts to address this for all age groups," says Angood. "From cradle to grave, everyone needs proper medication management. The extremes of age — the very young and very old — are well recognized as vulnerable populations for medication errors. So we do encourage organizations to look critically at those age groups and how they manage them."
Facilities with dedicated pediatric care units and pediatric-trained personnel already have expertise in these issues. A bigger concern is the general community hospitals that occasionally look after pediatric patients. "That is part of the reason we brought the alert forward," says Angood. "If this is a problem, then organizations should do something about it. And if they aren't doing something about it, they should start mobilizing the resources to do it."
The alert recommends that organizations take steps to be "transparent" when errors do occur. "Historically, there has been an approach that professionals knew best. As health care has become more complicated and more sophisticated, that paternalistic approach just doesn't hold anymore," says Angood. "But it remains to some degree, and it is very much under the microscope."
If errors do occur, they should be recognized, and providers should apologize for them and learn from them, says Angood. "That is where we are headed with the issue of transparency," he says. "That's what we are trying to push. Many errors occur every day that don't ever reach the light of day. People need to be able to recognize and report errors comfortably, in an environment that views them as a learning experience. That requires a cultural shift."
There is a "groundswell of concern" around the safety of the medication management processes for hospitalized children recently, according to Paul J. Sharek, MD, MPH, one of the above study's authors and chief clinical patient safety officer at Lucile Packard Children's Hospital in Stanford, CA.
The Joint Commission's standards currently do not address pediatric patients specifically. "This Sentinel Event Alert represents a recognition by The Joint Commission that medication management is quite different between adult and pediatric patients, with children posing several unique challenges," says Sharek. "Whether the Sentinel Event Alert may be the start of something new for The Joint Commission remains to be seen."
However, Sharek notes that only about 15% of hospitalized patients in the United States are children, which may be one reason that resources devoted to the quality of pediatric care lag far behind adult care.
"To some degree, it's our own fault," says Sharek. "Research has been largely focused on the quality and safety needs of adult patients. The science regarding quality and safety in the pediatric setting is emerging quickly, however — so we are catching up."
Reference
- Takata, GS, Mason W, Takatoma C, et al. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in U.S. children's hospitals. Pediatrics 2008; 121:e927-3935.
[For more information, contact:
Paul Sharek, MD, MPH, FAAP, Medical Director of Quality Management/Chief Clinical Patient Safety Officer, Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA 94304. Phone: (650) 736-0629. Fax: (650) 497-8465. E-mail: [email protected].]
Medication errors harm roughly one out of 15 hospitalized children, according to a new study. Researchers reported an 11.1% rate of adverse drug events in pediatric patients. Of those, 22% were deemed preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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