With greater than 1300 interventions in 2 months, the results of this study indicate the value and ability of pediatrics-trained clinical pharmacists to detect and prevent medication errors from reaching the patient. Of the interventions recorded, nearly one-third had the potential for error or harm to the patient and one-half of those were determined to have the potential to cause significant morbidity or mortality if not prevented. The multitude of other interventions made and recorded highlight the important role a pediatric clinical pharmacist can play when integrated into the inpatient pediatric team.
Most errors in this study occurred on the general pediatric ward and the least number of errors occurred in the NICU. The higher number of residents with less training and the heterogeneity of the pediatric population could help explain the increase in pediatric errors. In contrast, the NICU at our institution is a more homogenous population with a more experienced physician team and fewer resident physicians. In addition, fewer medications are used by this population than by the general pediatric population and a reduced pharmacy presence in rounds could help explain the discrepancies in medication errors noted.
It is noteworthy that resident physicians with the least number of years in training had the highest percentage of prescribing errors and need for pharmacist intervention. Despite second-year residents having the highest number of pharmacist interventions, first-year residents had the highest percentage of prescribing errors among all provider types. Second-year residents have a greater familiarity with the pediatric pharmacists than first-year residents, as well as having a greater comfort level in asking questions. Second-year residents are also staffing the PICU for the first time, which may help explain the higher percentages for pharmacist interventions in this group.
During the study period 11 documented, known errors reached the patient. Greater than 60% of these errors were prescribing errors that were missed upon pharmacist order entry and verification. Many of the prescribing errors can be attributed to the complexities of dosing in the pediatric population, as drug references for some medications are mg/kg/dose and others are mg/kg/day divided. Some of the prescribing errors missed by the pharmacist upon order entry may be explained by the lack of pediatric dosing knowledge and training by non-pediatric pharmacists, as well as the lack of dose-checking computer software at our institution.
It is likely that some errors were not accounted for in this study. Errors were only included if the pharmacist was aware the error had occurred; therefore, nursing administration errors and near misses are largely underreported in this study. In addition, the researchers could not determine the total number of pediatric medications written to produce an error rate per patient days given the pharmacy computer system limitations.
There are limited studies documenting the cost avoidance, prevention of medication errors and harm, and optimization of drug therapy associated with having clinical pharmacists in pediatrics. In 1987, Folli et al12
published their results relating to medication error prevention by clinical pharmacists in two children's hospitals. This study showed an error rate of 4.9 and 4.5 per 1000 medication orders in the two hospitals. Children younger than 2 years and pediatric intensive care patients tended to have received the greatest proportion of orders containing medication errors, whereas neonatal patients received the lowest rate. It was also noted the error rate was greatest among physicians with the least amount of training. The authors concluded pharmacist involvement in the review of medication orders dramatically reduced the potential harm from errors.
Kaushal et al9
evaluated medication errors in pediatric patients and discovered a 3-fold higher potential ADE rate than that of adults. Causes for the higher potential error rate have been speculated to be due to the challenges for ordering, dispensing, and administering of medications due to weight-based dosing, medication formulation, communication skills of children, and a child's innate physiology and inability to compensate for medication errors. This study reported a rate of 5.7% for errors, of which 19% were deemed preventable. Contrary to the study of Folli and collleagues,12
neonates in the NICU experienced a higher medication error rate and potential for ADEs than neonates in other pediatric wards. In addition, most medication errors were considered to be dosing errors and occurred during the stage of drug ordering. The investigators concluded that “ward-based clinical pharmacists potentially could have prevented the majority of errors.”
Holdsworth et al13
examined the impact and incidence of ADEs in pediatric inpatients and found that 61% of all ADEs were considered to be preventable. The most common error discovered was underdosing, followed by wrong drug choice and overdosing. Opiates and antibiotics tended to be the most commonly implicated medications prescribed that resulted in errors. The patients more often affected were children who had longer lengths of stay owing to increased medication exposure.
One study reviewed 200 cases of 10-fold prescribing errors, of which 45% were considered potentially serious and 19.5% occurred among pediatric patients. In addition, 10-fold errors accounted for 5.33% of all errors detected during the study period.14
In light of the pediatric studies reporting a higher rate for potential ADEs, the American Academy of Pediatrics released a policy statement in 2003 to help hospitals better prevent medication errors in pediatric patients.15
In 2008, the Joint Commission reiterated the American Academy of Pediatrics' guidance with the release of recommendations and mandates to aid in protection of children from ADEs caused by medication errors.2
In a review of the economic effects of clinical pharmacy interventions, De Rijdt et al5
reported a reduction in preventable ADEs, optimization of antibiotic therapy, as well as cost avoidance associated with clinical pharmacy services in the adult population. In one study4
reviewing the cost implications of having a critical care pharmacist present in the adult intensive care unit, cost avoidance for ADEs totaled between $205,919 and $280,421 in a 4.5-month time period, proving the financial benefit and incentives to having clinical pharmacists on the unit.
This prospective study highlighted the impact a pediatric pharmacist can make on the optimization of medication therapy and prevention of medication errors. The overall error rate per order image scanned was 5.9% during this time period; however, 5.7% of those errors were prevented by the pediatric pharmacist, showing a vast improvement in patient safety. Prevention of medication errors requires a team approach, and clinical pharmacists play an integral role in preventing medication errors and ADEs, as well as assisting in optimizing drug therapy for the pediatric population.