Safety first

Article Outline

• Copyright

This issue of The Journal contains three articles and an editorial discussing various aspects of patient safety as it applies to children. While both the peer-reviewed literature and the media have devoted increasing attention to hospital safety in the past decade, there has been minimal attention directed specifically to children in this setting.

Two of the papers involve the use of technology to reduce errors. Jani et al in London report the use of an electronic prescribing system to reduce errors in a subspecialty outpatient clinic. While electronic prescribing in the inpatient setting is increasingly studied, this represents the first report of such a system in children being treated in an outpatient setting. As might be hoped, there was an enormous improvement in such measures as legibility with the electronic system. A report from Hayden et al at St. Jude children’s Research Hospital describes the use of technology to prevent one of the banes of inpatient care: the improperly labeled laboratory specimen. This system, which employs bar coding and hand-held personal digital assistants, was estimated to have prevented over 60 mislabeling events during its first year. While a “mislabeling event” sounds rather benign, keep in mind that such events usually result in the pain of an additional specimen collection, or the delay in obtaining important information.

Dr. Levy, an expert in hospital safety for children from UT Southwestern Medical School, puts both of these studies into the context of broader safety initiatives with a provocative editorial.

Finally, a community-based study from Zandieh et al at Cornell, reminds us that medication errors are not limited to hospitals. These workers studied adverse drug events (ADEs) occurring during a two month period in a group of pediatric office practices in Boston. Using statistical techniques to identify the antecedents of ADEs, the investigators demonstrated that the major risk factor was the presence of multiple prescriptions; this factor was more important than language proficiency, race, parental education, and others. Very likely, the presence of multiple prescriptions was a marker for some medically complex children—a group at risk for adverse events in many clinical settings.

Pediatricians may be late to become interested in the importance of patient safety, but we hope these studies will bring this vitally important topic to the forefront and demonstrate The Journal’s commitment to highlighting this type of work.