Medications are an important part of the treatment of many illnesses in children. An adverse drug event (ADE) is any medication safety event that harms a patient or increases the risk of harm to a patient. Many adverse drug events can be prevented, and we work hard to avoid them every day. Some medication-related events are not preventable, such as an adverse reaction to a medication that a patient has never taken before.
Reducing ADEs is an important aspect of increasing patient safety. To do this, we review medication events when they occur to increase our awareness of how we can improve our systems to reduce the chance of these events happening again.
There are several types of adverse drug events. The less severe ADEs do not cause harm to patients; however, learning about these events may help us improve our patient care and safety. To track our quality of care, we focus on more serious ADEs that cause temporary or permanent harm, where additional care or hospitalization may be required.
How are we doing?
For patients admitted to the hospital, we track the number of adverse drug events that occur and record the severity of the event. Tracking the number of ADEs in this way helps us measure the effectiveness of our efforts to reduce them. The graph below shows serious adverse drug events, where some level of harm was caused to a patient.
As you can see in the graph, we consistently have low frequency of ADEs. Our goal, however, is to further reduce these medication-related events.
What are we doing to improve?
We track ADEs that occur in the hospital, and these data are reviewed by a committee of doctors, nurses, and administrators who recommend and implement changes to prevent similar events from occurring again. The strategies to prevent ADEs include identifying high risk events, pinpointing, if possible, common factors in the medication delivery system where improvements can be made. We provide feedback to our staff and identify ways to prevent future ADEs from occurring. We also use technical tools during drug preparation and administration including barcode scanning and computerized safety alerts that check dose ranges, allergies, and potential drug-to-drug interactions. Additionally, family representatives are part of our subject matter expert team to help us identify ways to continuously improve.
How do we collaborate with other hospitals to improve patient safety?
We submit our ADE data monthly to the Children's Hospitals' Solutions for Patient Safety (SPS)** national collaborative. More than 100 hospitals from around the United States participate in this network that tracks hospital-acquired conditions to share best practices regarding patient safety. The goal is not to compare performance, but to learn from each other and reduce serious harm across all hospitals.
* — Comparative Rate: SPS Network Aggregate Rate