Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital.
This study describes an effort to reduce adverse drug events (ADEs) at a pediatric tertiary care hospital through interventions targeting the clinical staff. These interventions included use of a Web-based tutorial on medication safety, a "zero-tolerance" policy whereby any medication errors would have to be rewritten, and feedback of individual data on prescribing error to clinicians. The intervention achieved impressive reductions in potential ADEs, defined as any incompletely written medication order, but did not document the incidence of ADEs resulting in patient harm. The baseline incidence of potential ADEs was also higher than that seen in prior research.