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