Medication Errors Hurt Kids the Most

The above is a headline coming from the March 07, 2007 edition of the Star-Ledger out of New Jersey. This article, and several more in other publications, were based on an investigation released by United States Pharmacopeia, an independent organization that sets quality standards for prescription and over-the-counter medicines sold in the United States. Another article based on the same study also appeared in the March 07, 2007 New York Times.

This report showed that the time surrounding surgery (called perioperative period) is the time of highest risk for being harmed by medication errors. The study showed that errors related to surgery are three times higher than in all other areas of a hospital combined. The report also showed that children are most likely to be harmed.

The rate of harm from medications was 5% for patients undergoing surgery. According to the articles this is much higher than the general risk level from medications. However, for children, the risk was reported to be over 12 percent.

Diane Cousins, a health care specialist at Pharmacopeia and one of the authors explained that the area of most common time for errors is when the patient was transferred from the preoperative team to the operating room and then to the recovery room and finally to the regular ward nurses,. "The system is often very fragmented," she stated. She also warned, "It's beyond troubling that the smallest, youngest patients are the ones most at risk. We need to move more towards system fixes."

The New York Times article also reported that Ms. Cousins stated that, "There are 10,000 drugs in the marketplace, and many have never been tested on children in clinical trials, so doses are often made by guesswork based on weight, involving conversion of pounds to kilograms, sometimes by nurses who are not pediatric specialists."

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