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Published: Monday, April 7, 2008
One in 15 kids hurt by medication in hospital
By Lindsey Tanner Associated Press
CHICAGO -- Roughly one out of 15 hospitalized children are harmed by medicine mix-ups, accidental overdoses and bad drug reactions, according to the first scientific test of a new detection method.
That number is far higher than earlier estimates.
Researchers found a rate of 11 drug-related harmful events for every 100 hospitalized children. That contrasts 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.
Traditional methods include nonspecific patient chart reviews and voluntary error reporting.
The study is being released today 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 prompted 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.
While 22 percent of the problems with children in the study were considered preventable, most were relatively mild. None was fatal or caused permanent damage, but some "did have the potential to cause some significant harm," said Dr. Paul Sharek, medical director of quality at Stanford University's Lucile Packard Children's Hospital and the author of the study.
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.
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.
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