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What is the largest single category of adverse events due to medical error experienced by hospitalized pediatric patients?

A. Surgical site infections

B. Central line–associated blood stream infections

C. Catheter-associated urinary tract infections (UTIs)

D. Ventilator-associated pneumonia

E. Adverse drug events

Answer: E

Reference: Frush KS, Krug SE. Pediatric medication safety, in Pediatric Patient Safety and Quality Improvement. New York, NY: McGraw-Hill; 2015.

In 1999, the Institute of Medicine (IOM) estimated in their seminal report, To Err Is Human, that between 44,000 and 98,000 deaths occur annually in the United States due to medical errors, with an estimate of 7000 deaths annually attributed to medication errors. In the IOM’s 2007 report, Preventing Medication Errors: Quality Chasm Series, they estimated that 400,000 preventable adverse drug events occur annually in US hospitals. Medication errors are the most prevalent type of iatrogenic adverse events in US health care. Medication errors can occur at any point in the manufacturing, prescribing, or administration of a medication to a patient.

Pediatric patients are particularly vulnerable to medication errors because of the calculations required for weight-based dosing, developing organ systems, and decreased ability to report side effects or self-advocate. Some studies have suggested that pediatric patients experience up to 3-fold more adverse drug events compared to adults. In 2010, the Centers for Medicare and Medicaid Services (CMS) estimated the incidence of hospital-acquired conditions in the United States to be as follows: adverse drug events, 1,900,000/year; catheter-associated UTIs, 530,000/year; central line–associated blood stream infections, 40,000/year; surgical site infections, 110,000/year; and ventilator-associated pneumonia, 40,000/year.

References

  1. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

  2. Aspden P, Wolcott JA, Bootman JL, Cronenwett LR. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academy Press; 2007.

  3. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120.

  4. Ferranti J, Horvath M, Cozart H, et al. Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment. Pediatrics. 2008;121:1201-1207.

  5. Agency for Healthcare Research and Quality. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No. 16-0006-EF. http://www.ahrq.gov/professionals/qualitypatient-safety/pfp/index.htm. Accessed November 18, 2020.

Kevin, a 6-year-old patient with cerebral palsy and a seizure disorder, is admitted for pneumonia. Shortly after admission, he is found unresponsive in his bed. You discover ...

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