• Article
  • March 14, 2018

How 3 Children's Hospitals Improved Medication Safety

Medication errors are one of the biggest safety issues facing hospitals today.

An Institute of Medicine study estimates that on average, a hospital patient is subject to at least one medication error per day. For pediatric patients, the danger is heightened because of their lower body weights—even a tiny error can have catastrophic results. Here are three ways children's hospitals are working to reduce medication errors.

Antibiotic stewardship program

In 2013, Nationwide Children's Hospital in Columbus, Ohio, initiated an antibiotic stewardship program (ASP)—a program focused on driving improvements in antibiotic use in surgical areas and across all the hospital's services. The ASP develops guidelines to help providers determine what antibiotics should be prescribed and when they should be discontinued. It also performs multidisciplinary quality improvement in various clinical domains—including inpatient, primary care, urgent care and ED.

The following year, Nationwide Children's began using data from the Children's Hospital Association's Pediatric Health Information System (PHIS), a comparative pediatric database that helps hospitals drive decision-making and education about antibiotic use.

Nationwide is also a member of the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) program, a collaboration of about two dozen children's hospitals focusing on using prescribing data to establish best practices for the use of antibiotics among hospitalized children.

Read more about Nationwide's antibiotic stewardship program.

ENFit tubing transition

Three years ago, The Joint Commission (TJC) issued a Sentinel Event Alert urging vigilance among health care organizations regarding the transition to globally accepted standards for tubing connections.

The compatibility of different types of tubing connections has presented potential danger to patients—the alert cited more than 100 errors resulting in 21 deaths due to misconnections involving enteral feeding tubes and IV lines alone. The transition to ENFit products is aimed at reducing or eliminating adverse events associated with tubing misconnections.

The ENFit system is incompatible with the traditional Luer lock system, so it prevents linking of an ENFit syringe to non-ENFit products – such as IV and respiratory tubing – to prevent an adverse event. A team of clinicians from Children's Mercy Kansas City established a series of guidelines to work through this transition and published an article in the American Journal of Health-System Pharmacy detailing those practices.

Read more about how Children's Mercy's transition to ENFit.

Data analytics software

Clinicians at The Children's Hospital of Philadelphia (CHOP) spent more than two years building an expansive pharmaceutical library and accompanying software to improve medication safety for its patients. The software aggregates medication administrative data and presents it to hospital safety leaders so they can better monitor key safety metrics.

It also uses error-reduction algorithms so that hospital staff can more easily identify problem areas and make universal changes on the fly. In essence, this new technology automates and digitizes what has traditionally been a highly manual and paper-driven process, which can lead to errors.

While the product was under development, word began to spread about what was happening at CHOP – hospitals around the world expressed interest. To meet the growing demand, CHOP spun the technology out as a separate company, Bainbridge Health.

Last April, Bainbridge Health launched the technology commercially and now hosts more than 30 hospitals on the platform. During that time, the application has aggregated, analyzed and provided quality improvement opportunities on more than 20 million medication administrations on its network across the United States.

Read more about CHOP's work with data analytics.

Send questions or comments to magazine@childrenshospitals.org.