Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative

Pediatrics

Volumn 128, Issue 2, 2011, Pages

  Tham, Eric ^a,b   Calmes, Helen M ^c   Poppy, Amy ^b   Eliades, Aris B ^d   Schlafly, Stacey Morgan ^e   Namtu, Katie C ^f   Smith, Dani M ^d   Vitaska, Matthew C ^b   McConnell, Cindy ^b   Potts, Amy L ^e   Jastrzembski, Jenny ^g   Logsdon, Tina R ^h   Hall, Matthew ^h   Takata, Glenn S ^i,j  

^a University of Colorado Denver and Children s Hospital Colorado   (United States)

^b CHILDREN S HOSPITAL COLORADO   (United States)

^c CHILDREN S HOSPITAL   (United States)

^d AKRON CHILDREN'S HOSPITAL   (United States)

^e MONROE CARELL JR CHILDREN S HOSPITAL AT VANDERBILT   (United States)

^f JOHNS HOPKINS ALL CHILDREN S HOSPITAL   (United States)

^g MIAMI CHILDREN'S HOSPITAL   (United States)

^h Child Health Corporation of America   (United States)

ⁱ UNIVERSITY OF SOUTHERN CALIFORNIA   (United States)

^j CHILDREN S HOSPITAL LOS ANGELES   (United States)

more..

Author keywords

Adverse drug events; Patient safety; Pediatrics

Indexed keywords

ANTIEMETIC AGENT; CREATININE; DIPHENHYDRAMINE; FLUMAZENIL; GLUCOSE; HEPARIN; INSULIN; LAXATIVE; LOW MOLECULAR WEIGHT HEPARIN; NALOXONE; NARCOTIC AGENT; OPIATE; POLYSTYRENESULFONATE SODIUM; POTASSIUM;

ADVERSE DRUG REACTION; ANTICOAGULATION; ARTICLE; CLINICAL PROTOCOL; CONSENSUS DEVELOPMENT; CONTROLLED STUDY; CREATININE BLOOD LEVEL; DECISION SUPPORT SYSTEM; DRUG DELIVERY SYSTEM; FALLING; GLUCOSE BLOOD LEVEL; HIGH RISK PATIENT; HUMAN; HYPOGLYCEMIA; HYPOTENSION; LETHARGY; OUTCOME ASSESSMENT; PATIENT SAFETY; PRESCRIPTION; PRIORITY JOURNAL; RASH; RISK FACTOR; SEDATION; STANDARDIZATION; UNSPECIFIED SIDE EFFECT;

ADVERSE DRUG REACTION REPORTING SYSTEMS; COOPERATIVE BEHAVIOR; DRUG TOXICITY; HUMANS; MEDICATION SYSTEMS, HOSPITAL; PHARMACEUTICAL PREPARATIONS;

EID: 80051494423     PISSN: 00314005     EISSN: 10984275     Source Type: Journal    
DOI: 10.1542/peds.2010-3772     Document Type: Article

References (24)

1. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-2120 (Pubitemid 32367829)
2. Holdsworth MT, Fichtl RE, Behta M, et al. Incidence and impact of adverse drug events in pediatric inpatients. Arch Pediatr Adolesc Med. 2003;157(1):60-65 (Pubitemid 36343419)
3. Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics. 2008;121(4). Available at: www.pediatrics.org/cgi/content/full/121/4/e927
4. Takata GS, Taketomo CK, Waite S; California Pediatric Patient Safety Initiative. Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65(21):2036-2044
5. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277(4):307-311 (Pubitemid 27045011)
6. Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277(4):301-306 (Pubitemid 27045010)
7. Aspden P; Institute of Medicine, Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors. Washington, DC: National Academies Press; 2007
8. Sharek PJ, McClead RE Jr, Taketomo C, et al. An intervention to decrease narcotic-related adverse drug events in children's hospitals. Pediatrics. 2008;122(4). Available at: www.pediatrics.org/cgi/content/full/122/4/e861
9. Institute for Healthcare Improvement. The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. Boston, MA: Institute for Healthcare Improvement; 2003
10. Langley GJ. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass; 1996
11. Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-690
12. Pape TM, Guerra DM, Muzquiz M, et al. Innovative approaches to reducing nurses' distractions during medication administration. J Contin Educ Nurs. 2005;36(3):108-116
13. Nguyen EE, Connolly PM, Wong V. Medication safety initiative in reducing medication errors. J Nurs Care Qual. 2010;25(3):224-230
14. Conrad C, Fields W, McNamara T, Cone M, Atkins P. Medication room madness: calming the chaos. J Nurs Care Qual. 2010;25(2):137-144
15. Cohen MR, Anderson RW, Attilio RM, Green L, Muller RJ, Pruemer JM. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm. 1996;53(7):737-746 (Pubitemid 26112665)
16. Institute for Safe Medication Practices. Santa checks his list twice: shouldn't we? Available at: www.ismp.org/newsletters/acutecare/articles/ 20091217.asp. Accessed April 18, 2011
17. Dickinson A, McCall E, Twomey B, James N. Paediatric nurses' understanding of the process and procedure of double-checking medications. J Clin Nurs. 2010;19(5-6):728-735
18. Institute for Safe Medication Practices. The virtues of independent double checks: they are worth your time! Available at: www.ismp.org/newsletters/ acutecare/articles/20030306.asp. Accessed April 18, 2011
19. White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Qual Saf Health Care. 2010;19(6):562-567
20. Smetzer JL. Reducing at-risk behaviors. Jt Comm J Qual Patient Saf. 2005;31(5):294-299, 241
21. Hertzel C, Sousa VD. The use of smart pumps for preventing medication errors. J Infus Nurs. 2009;32(5):257-267
22. Weir VL. Best practice protocols: preventing adverse drug events. Nurs Manage. 2005;36(9):24-30
23. Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of "corollary orders"to prevent errors of omission. J Am Med Inform Assoc. 1997;4(5):364-375 (Pubitemid 127433631)
24. Kowiatek JG, Weber RJ, Skledar SJ, Frank S, DeVita M. Assessing and monitoring override medications in automated dispensing devices. Jt Comm J Qual Patient Saf. 2006;32(6):309-317