… reliable data source for medication error detection. … Ni  Y, Lingren T, Huth H, et al. Integrating and evaluating the data …

Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found that pump alerts do not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific patients and medications (such as fentanyl, insulin and vasopressin). The study also identified 160 attempts to exceed the programmed dosing limit; while these represented a small number of violations over the entirety of the study period, the attempts involved high-risk medications (including fentanyl, insulin, and morphine) and doses programmed at 5- to 24-times the maximum dose which could result in significant adverse patient outcomes.

Preventing medication administration errors remains challenging. In this prospective study, investigators found that implementation of an automated system for detecting medication administration errors in a single neonatal intensive care unit improved identification of errors.

Taxonomies help to consistently organize data and evidence for use in research. This commentary describes the development of a terminology specific to adverse events in children for use in various settings. The authors note that the tool will be continuously updated and is expected to mature over time.

… patients at risk for dosing errors. … Hagedorn PA, Kirkendall ES, Kouril M, et al. Assessing Frequency and Risk …

Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.

… based on the Institute for Healthcare Improvement's Global Trigger Tool . In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a …

Comparing the accuracy of electronic dosing rules provided by a commercial vendor with traditional clinical dosing rules in pediatrics, this stimulation study found that the electronic rules were accurate only 55% of the time. This finding highlights the possible unintended consequences of health information technology (IT) on patient safety and underscores the specific challenge of pediatric medication prescribing. A recent AHRQ WebM&M commentary examines the complex issues around medication dosing for pediatric patients.

… adverse event detection system at two academic children's hospitals. Similar to prior studies , the automated …

… … Pediatrics … The Institute for Healthcare Improvement's (IHI) Global Trigger Tool is a well-established sampling …