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Journal Article > Study
Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.
Call RJ, Burlison JD, Robertson JJ, et al. 2014;165:447-452.
To investigate the utility of a trigger tool in detecting adverse drug events (ADEs) in pediatric hematology and oncology patients, this study compared the tool with a voluntary reporting system. Implementation of the trigger tool led to inclusion of many cases that were not ADEs (false positives). In contrast, voluntary reporting did not identify all ADEs that were found using the trigger tool, implying under-reporting. These results reinforce prior research suggesting that multiple detection methods are needed to comprehensively detect ADEs. The authors advocate for triggers to be refined according to patient population and hospital setting to augment their usefulness. A previous AHRQ WebM&M perspective discusses the role of trigger tools in identifying ADEs and measuring patient safety.
Journal Article > Study
Medication errors in the homes of children with chronic conditions.
Walsh KE, Mazor KM, Stille CJ, et al. Arch Dis Child. 2011;96:581-586.
Medication errors can be difficult to detect in ambulatory care, as patients or caregivers administer medications instead of health care providers. This descriptive study used home visits to children with chronic diseases to identify medication errors committed by parents, and found a remarkably high incidence of errors, particularly when parents did not use aids or support tools to help with medication administration. Although many errors were attributable to suboptimal provider–patient communication, physicians were unaware of errors in 80% of cases. An AHRQ WebM&M commentary discusses the effects of parental misunderstanding of medication instructions for their child.