May 4, 2001

A six-week study collaboration among researchers at the MGH, BWH and Children's Hospital Boston found that serious medication errors occurred with pediatric patients three times more often than with adult patients — even though the preventable rate between pediatric and adult academic medical hospitals is similar.

The study, which was published in the April 25 issue of the Journal of the American Medical Association, found that the way drugs are packaged by the pharmaceutical industry makes pediatric drug dispensing particularly prone to errors. Most medications are packaged in adult doses and/or at adult strengths. Physicians, nurses and pharmacists caring for children must calculate and prepare dosages for patients ranging from the tiniest premature babies to toddlers, school-age children, teens and sometimes adults. This creates opportunities for error that do not arise in adult patient settings. These errors also are more likely to cause adverse outcomes because smaller patients are less able to tolerate dosage errors.

The study used data collected at MassGeneral Hospital for Children and Children's Hospital Boston from medical and surgical units, pediatric intensive care units and a neonatal intensive care unit. A multidisciplinary team identified incidents by soliciting reports from house staff, nurses and pharmacists, and from daily medication order sheets, medication administration records and chart review. Incidents were classified as medication errors, potential adverse drug events (ADEs) or actual ADEs. The incidents were rated on severity and attribution (whether the event was caused by the drug) by two independent reviewers.

The study's authors found that most of the errors occurred at the point of physician ordering and were most commonly dosing errors. Other error-causing factors included route of administration, transcription and documentation into the medication administration record, date and frequency of administration. The authors suggest that the majority of potential and preventable ADEs in this study could have been prevented by computerized order entry with clinical decision support (drug-allergy checks, drug-dose checks and drug-drug interaction checks). In addition, they also identified the assignment of full-time, ward-based pharmacists as an effective error prevention strategy.

Members of the study group included Rainu Kaushal, MD, MPH, of BWH, who led the study, with Margaret Clapp, RPh, of MGH Pharmacy; David W. Bates, MD, of BWH; and Christopher Landrigan, MD, MPH; Frank Federico, RPh; Kathryn McKenna; and Donald Goldmann, MD, all of Children's Hospital. The study was supported by the Harvard Risk Management Foundation.