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GLENN S. TAKATA, M.D., M.S., is Attending Physician, Division of General Pediatrics, and Medical Director for Patient Safety, Patient Safety Program, Children’s Hospital Los Angeles (CHLA), Los Angeles, CA, and Assistant Professor of Clinical Pediatrics, Department of Pediatrics, Keck School of Medicine, University of Southern California (USC), Los Angeles. CAROL K. TAKETOMO, PHARM.D., is Director, Pharmacy and Nutrition, CHLA, and Adjunct Assistant Professor, Department of Pharmacy Practice, School of Pharmacy, USC. STEVEN WAITE, PHARM.D., is Pharmacy Manager, Clinical Pharmacy, Children’s Hospital Central California, Madera, and Adjunct Professor of Pharmacy, Long School of Pharmacy, University of the Pacific, Stockton.

Address correspondence to Dr. Takata at the Division of General Pediatrics, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, MS 76, Los Angeles, CA 90027 (gtakata{at}chla.usc.edu).

Purpose. The characteristics of medication errors and adverse drug events (ADEs) in hospitals participating in the California Pediatric Patient Safety Initiative (CaPPSI) were studied to identify opportunities for improvement. Methods. Data were collected to identify pharmacy intervention medication errors (PIMEs) with significant harm potential and ADEs identified by a validated pediatric trigger method (TADEs) and by voluntary incident reports (VADEs) from November 2003 through April 2004. Electronic trigger identification was used. The primary outcomes measured were PIMEs, TADEs, and VADEs and the characteristics of these medication errors and ADEs. A secondary outcome measure was the positive predictive value of the trigger tool. Results. The rates of PIMEs, TADEs, and VADEs were 2.67, 22.3, and 1.7 per 1000 patient days, respectively. PIMEs and ADEs occurred mostly among patients age one year or older during days 0 and 1 of admission and involved the following medication categories: antiinfectives and antibiotics, analgesics and antipyretics, and electrolytic-, caloric-, and water balance-replacement preparations. Most PIMEs involved an incorrect dosage or the wrong drug. Primary diagnoses differed between those with PIMEs and VADEs and those with TADEs. All medication processes were in need of improvement except dispensing. The trigger tool identified more ADEs than did voluntary incident reports by a factor of 11 and had a positive predictive value of 16.8%. Conclusion. Baseline rates of PIMEs, TADEs, and VADEs for pediatric hospitals in California were determined through collaborative efforts of CaPPSI facilities. Identification of ADEs was more effective when a trigger tool was used than when incidents were voluntarily reported. Index terms: Data collection; Dosage; Drugs, adverse reactions; Errors, medication; Hospitals; Methodology; Pediatrics; Pharmacy, institutional, hospital; Quality assurance; Reports