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Study: Medicine mix-ups hurt about 1 in 15 hospitalized kids

By LINDSEY TANNER, AP Medical Writer  Tuesday, April 15, 2008

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CHICAGO -- Medicine mix-ups, accidental overdoses and bad drug reactions harm roughly one out of 15 hospitalized children, according to the first scientific test of a new detection method.

That number is far higher than earlier estimates and bolsters concerns already heightened by well publicized cases like the accidental drug overdose of actor Dennis Quaid's newborn twins last November.

"These data and the Dennis Quaid episode are telling us that ... these kinds of errors and experiencing harm as a result of your health care is much more common than people believe. It's very concerning," said Dr. Charles Homer of the National Initiative for Children's Healthcare Quality. His group helped develop the detection tool used in the study.

Researchers found a rate of 11 drug-related harmful events for every 100 hospitalized children. That compares with an earlier estimate of two per 100 hospitalized children, based on traditional detection methods. The rate reflects the fact that some children experienced more than one drug treatment mistake.

The new estimate translates to 7.3 percent of hospitalized children, or about 540,000 kids each year, a calculation based on government data.

Simply relying on hospital staffers to report such problems had found less than 4 percent of the problems detected in the new study.

The new monitoring method developed for the study is a list of 15 "triggers" on young patients' charts that suggest possible drug-related harm. It includes use of specific antidotes for drug overdoses, suspicious side effects and certain lab tests.

By contrast, traditional methods include nonspecific patient chart reviews and voluntary error reporting.

The researchers said their findings highlight the need for "aggressive, evidence-based prevention strategies to decrease the substantial risk for medication-related harm to our pediatric inpatient population."

The study was released Monday in the April issue of the journal Pediatrics.

It involved a review of randomly selected medical charts for 960 children treated at 12 freestanding children's hospitals nationwide in 2002. Triggers mentioned in the charts promoted an in-depth review of the patients' care.

Patient safety experts said the problem is likely even bigger than the study suggests because it involved only a review of selected charts. Also, the study didn't include general community hospitals, where most U.S. children requiring hospitalization are treated.

Study author Dr. Paul Sharek said evidence is needed to show whether a big push to prevent medical errors in recent years has put a dent in the problem since 2002, when the data were gathered.

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