Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Children’s Hospitals Pediatrics
April 2008; Volume 121, Number 4; pp. e927-e935
Glenn S. Takata, MD; Wilbert Mason, MD, MPH; Carol Taketomo, PharmDe; Tina Logsdon, MSf; Paul J. Sharek, MD, MPHg.
KEY POINTS FROM DAN MURPHY
1. Older data, using outdated methods of investigation indicate: “Data using the established Harvard Medical Practice Study methodology revealed a 2.3 percent rate of adverse drug events (ADE’s) in the pediatric inpatient population.”
2. This study, using the “trigger method” of investigation, reveals: “Use of this more sophisticated detection tool identified an 11.1 percent rate of ADE’s in pediatric inpatients.”
3.This study used the “trigger method” to identify adverse events to children in hospitals, noting that the “trigger method” identifies adverse event rates as “much as fifty times higher than hospital-based occurrence reporting strategies and identifying adverse rates in high risk populations as high as 112 per 100 patients, with adverse drug event rates of 20 per 100 patients.” [WOW!]
4.In this study: “Twenty-two percent of all adverse drug events were deemed preventable, 17.8 percent could have been identified earlier, and 16.8 percent could have been mitigated more effectively.”
5. Only 3.7 percent of adverse drug events were identified in existing hospital-based occurrence reports, which constitute traditional voluntary reporting methods. [Very Important: This indicates that traditional methods of reporting hospital adverse drug events only report the “tip of the iceberg.”]
6. “Adverse drug event rates in hospitalized children are substantially higher than previously described.”
7. “The Institute of Medicine concluded that between 44,000 and 98,000 lives are lost per year in US hospitals as a result of error.”
8. “Recent data from the Harvard group using more sophisticated detection methods revealed a 6.5 percent rate of adverse drug events (ADE’s) alone in the adult inpatient setting, with 33 percent of these events described as preventable.”
9. “The medication class that most frequently was associated with an adverse drug event was analgesics/opioids (51 percent).”
10. 2.8 percent of adverse drug events cause severe harm, from one of the following categories: [Important]
• Contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization
• Contributed to or resulted in permanent patient harm
• Required intervention to sustain life
• Contributed to or resulted in the patient’s death
Dr. Dan Murphy graduated magna cum laude from Western States Chiropractic College in 1978. He received Diplomat status in Chiropractic Orthopedics in 1986. Since 1982, Dr. Murphy has served part-time as undergraduate faculty at Life Chiropractic College West, currently teaching classes to seniors in the management of spinal disorders. He has taught more than 2000 postgraduate continuing education seminars. Dr. Murphy is a contributing author to both editions of the book Motor Vehicle Collision Injuries and to the book Pediatric Chiropractic. Hundreds of detailed Article Reviews, pertinent to chiropractors and their patients, are available at Dr. Murphy’s web page, www.danmurphydc.com