Narrow Results Clear All
Search results for "Children's Hospitals"
Journal Article > Study
Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years.
Zhong W, Feinstein JA, Patel NS, Dai D, Feudtner C. BMJ Qual Saf. 2016;25:233-240.
Even in the era of electronic prescribing, look-alike and sound-alike drug names remain a safety vulnerability. In 2007, the Food and Drug Administration adopted Tall Man lettering, in which specific letters in drug names are printed in capital letters to avoid being mistaken for a look-alike or sound-alike medication (e.g., DOPamine; DOBUTamine). Despite widespread use of Tall Man lettering, it is unclear whether this strategy reduces errors. In this interrupted time series analysis, investigators pre-specified 12 look-alike, sound-alike drug errors in pediatric medication use and examined whether the frequency of these errors changed after Tall Man lettering was introduced. Although such errors were rare to begin with, they found no reduction after implementation of Tall Man lettering. This finding suggests that other interventions should be explored to avoid look-alike and sound-alike drug errors. This research also demonstrates the importance of evaluating safety interventions, which may have minimal impact despite face validity.
Journal Article > Study
Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.
Han YY, Carcillo JA, Venkataraman ST, et al. Pediatrics. 2005;116:1506-1512.
Although computerized physician order entry (CPOE) prescribing systems are commonly believed to improve patient safety and outcomes, this single-hospital study discovered increased mortality rates after implementation. Investigators retrospectively analyzed several variables in the 13 months before and 5 months following implementation. Even after adjustment for mortality variables, CPOE was independently associated with 3.28 greater odds for mortality. Additional findings include the workflow challenges and increased time required to enter orders compared with traditional handwritten practices. Given the national interest in CPOE, these findings should reinforce the understanding that CPOE is a tool rather than a solution for patient safety and that appropriate vigilance in implementation is necessary.