Date:
04/06/2008 05:29 PM Medicine mix-ups hurt about 1 in 15 hospitalized kids,
study of dozen US hospitals shows
By LINDSEY TANNER
AP Medical Writer
CHICAGO (AP) _ Medicine mix-ups, accidental
overdoses and bad drug reactions harm roughly one out of 15
hospitalized children, according to the first scientific test
of a new detection method.
That number is far higher than earlier estimates
and bolsters concerns already heightened by well publicized
cases like the accidental drug overdose of actor Dennis Quaid's
newborn twins last November.
"These data and the Dennis Quaid episode
are telling us that ... these kinds of errors and experiencing
harm as a result of your health care is much more common than
people believe. It's very concerning," said Dr. Charles
Homer of the National Initiative for Children's Healthcare
Quality. His group helped develop the detection tool used
in the study.
Researchers found a rate of 11 drug-related
harmful events for every 100 hospitalized children. That compares
with an earlier estimate of two per 100 hospitalized children,
based on traditional detection methods. The rate reflects
the fact that some children experienced more than one drug
treatment mistake.
The new estimate translates to 7.3 percent
of hospitalized children, or about 540,000 kids each year,
a calculation based on government data.
Simply relying on hospital staffers to report
such problems had found less than 4 percent of the problems
detected in the new study.
The new monitoring method developed for the
study is a list of 15 "triggers" on young patients'
charts that suggest possible drug-related harm. It includes
use of specific antidotes for drug overdoses, suspicious side
effects and certain lab tests.
By contrast, traditional methods include nonspecific
patient chart reviews and voluntary error reporting.
The researchers said their findings highlight
the need for "aggressive, evidence-based prevention strategies
to decrease the substantial risk for medication-related harm
to our pediatric inpatient population."
The study is being released Monday in the
April issue of the journal Pediatrics.
It involved a review of randomly selected
medical charts for 960 children treated at 12 freestanding
children's hospitals nationwide in 2002. Triggers mentioned
in the charts promoted an in-depth review of the patients'
care.
Patient safety experts said the problem is
likely even bigger than the study suggests because it involved
only a review of selected charts. Also, the study didn't include
general community hospitals, where most U.S. children requiring
hospitalization are treated.
Study author Dr. Paul Sharek said evidence
is needed to show whether a big push to prevent medical errors
in recent years has put a dent in the problem since 2002,
when the data were gathered.
Homer, of the children's healthcare initiative,
said some hospitals have started using trigger methods similar
to those in the study. But he added, "we still have a
long way to go."
Among triggers on the list was use of the
drug naloxone, an antidote for an overdose of morphine and
related painkillers. Symptoms include breathing difficulty
and very low blood pressure.
More than half the problems the study found
were related to these powerful painkillers, including overdoses
and allergic reactions.
While 22 percent of the problems were considered
preventable, most were relatively mild. None were fatal or
caused permanent damage, but some "did have the potential
to cause some significant harm," said Sharek, who is
medical director of quality at Stanford University's Lucile
Packard Children's Hospital.
Other triggers included use of vitamin K,
an antidote for an overdose of the blood thinner Coumadin;
use of a blood test that detects insulin overdoses; and a
lab test that identifies blood-clotting problems that can
come from an overdose of the blood thinner heparin and other
drugs.
Quaid's twins got accidental life-threatening
heparin overdoses in a Los Angeles hospital shortly after
they were born last November. The actor and his wife, Kimberly,
have since formed a foundation to prevent medical errors.
The babies recovered and Quaid said in an interview with The
Associated Press on Saturday that "they appear to be
normal kids, very happy and healthy."
Quaid praised the new study for raising awareness
about an under-recognized problem, and said he'd never envisioned
having to play the role of public health advocate before the
harrowing experience. He called it "the most frightening
time" of his life.
Quaid's advice to parents of hospitalized
children?
"Every time a caregiver comes into the
room, I would check and ask the nurse what they're giving
them and why," Quaid said.
Allen Vaida of the Institute for Safe Medication
Practices said trigger methods like those used in the study
can help. Still, a more comprehensive approach is needed,
he said, to detect the most serious, least common errors like
those involving the Quaids.
Voluntary reporting by hospital staffers is
still needed, along with methods to detect errors in time
to prevent or lessen any harm to patients, Vaida said.
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On the Net:
American Academy of Pediatrics: http://www.aap.org
National Initiative for Children's Healthcare
Quality: http://www.nichq.org
Institute for Healthcare Improvement: http://www.ihi.org
