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JAMA Study Finds Pharmacist Involvement Critical for Reducing Med Errors in Children

Cheryl A. Thompson

Assigning clinical pharmacists to pediatric units in hospitals would prevent most of the medication errors that occur, according to a study published in today’s Journal of the American Medical Association (JAMA). The study found that potential adverse drug events (ADEs) occur three times as often in hospitalized children as in adults.

Researchers reviewed 10,778 medication orders at a children’s hospital and the pediatric wards at a general hospital and found 616 medication errors (5.7 percent), 115 potential ADEs (1.1 percent), and 26 ADEs (0.24 percent). The rate of potential ADEs was three times that found in a 1992 study conducted in an adult patient population (1.1 percent versus 0.35 percent). Potential ADEs occurred at a significantly higher rate in neonates than in other hospitalized children. Most of the potential ADEs (79 percent) occurred during ordering. Incorrect doses were responsible for 34 percent of the potential ADEs.

Physician evaluators noted that ward-based clinical pharmacists could have prevented most of the potential ADEs (94 percent) and medication errors (95 percent). "The presence of clinical pharmacists on work rounds may lead to more informed clinical decisions by physicians," said the study’s authors. The researchers also recommended that clinical pharmacists assume leadership in error-prevention activities in pediatric wards, including monitoring the transcription of medication orders, developing drug therapy protocols, and overseeing drug preparation and storage.

"Pharmacists play an extremely vital role in protecting our most vulnerable patients from avoidable harm," said Henri R. Manasse, Jr., Ph.D., Sc.D., executive vice president and chief executive officer of ASHP. "These findings are more evidence that pharmacists’ involvement in patient care makes a difference."

The study also found that a computerized physician order-entry system equipped with clinical decision-support tools, such as allergy, dose, and drug interaction checks, could have prevented most of the errors.