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PSNet: Patient Safety Network
Journal Article

Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.

Takata GS, Mason W, Taketomo C, et al. Pediatrics. 2008;121:e927-35.

The use of trigger methodology to detect medical errors, including adverse drug events, has been widely validated in adult inpatients. This study reports on the development of a trigger tool to detect medication errors in pediatric patients. Using techniques similar to prior studies in adults, researchers developed a list of clinical events that may have signified an adverse event, such as use of vitamin K to treat coagulopathy. Trained reviewers retrospectively reviewed all charts where a trigger was found for evidence of an adverse event. The trigger tool identified a much higher rate of adverse drug events than found previously in pediatric patients and proved superior to voluntary error reporting at identifying both preventable and nonpreventable errors.