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JENNIFERL. COSTELLO, PHARM.D., is Pediatric Clinical Pharmacist, Children’s Hospital of New Jersey at Newark Beth Israel Medical Center (NBIMC), Newark. DEBORAHLLOYDTOROWICZ, M.S.N., RN, PH.D.(C), is Pediatric Nurse Practitioner, Children’s Hospital of Philadelphia; at the time of this study she was Nursing Director, Pediatric Critical Care and Cardiac Nursing, Children’s Hospital of New Jersey at NBIMC. TIMOTHYS. YEH, M.D., is Chairman, Department of Pediatrics, and Division Director, Pediatric Critical Care, Children’s Hospital of New Jersey at NBIMC.

Address correspondence to Dr. Costello at Children’s Hospital of New Jersey, Newark Beth Israel Medical Center, 201 Lyons Avenue, Newark, NJ 07112 (jcostello{at}sbhcs.com).

Purpose. The effects of a pharmacist-led pediatrics medication safety team (PMST) on the frequency and severity of medication errors reported were studied. Methods. This study was conducted in a pediatric critical care center (PCCC) in three phases. Phase 1 consisted of retrospective collection of medication-error reports before any interventions were made. Phases 2 and 3 included prospective collection of medication-error reports after several interventions. Phase 2 introduced a pediatrics clinical pharmacist to the PCCC. A pediatrics clinical pharmacist-led PMST (including a pediatrics critical care nurse and pediatrics intensivist), a new reporting form, and educational forums were added during phase 3 of the study. In addition, education focus groups were held for all intensive care unit staff. Outcomes for all phases were measured by the number of medication-error reports processed, the number of incidents, error severity, and the specialty of the reporter. Results. Medication-error reporting increased twofold, threefold, and sixfold between phases 1 and 2, phases 2 and 3, and phases 1 and 3, respectively. Error severity decreased over the three time periods. In phases 1, 2, and 3, 46%, 8%, and 0% of the errors were classified as category D or E, respectively. Conversely, the reporting of near-miss errors increased from 9% in phase 1 to 38% in phase 2 and to 51% in phase 3. Conclusion. An increase in the number of medication errors reported and a decrease in the severity of errors reported were observed in a PCCC after implementation of a PMST, provision of education to health care providers, and addition of a clinical pharmacist. Index terms: Clinical pharmacists; Documentation; Education; Errors, medication; Forms; Health professions; Hospitals; Interventions; Pediatrics; Reports; Team