Evaluating the Potential Severity of Look-Alike, Sound-Alike Drug Substitution Errors in Children.

OBJECTIVE: Look-alike, sound-alike (LASA) drug name substitution errors in children may pose potentially severe consequences. Our objective was to determine the degree of potential harm pediatricians ascribe to specific ambulatory LASA drug substitution errors. METHODS: We developed a unified list of LASA pairs from published sources, removing selected drugs on the basis of preparation type (eg, injectable drugs). Using a modified Delphi method over 3 rounds, 38 practicing pediatricians estimated degree of potential harm that might occur should a patient receive the delivered drug in error and the degree of potential harm that might occur from not receiving the intended drug. RESULTS: We identified 3550 published LASA drug pairs. A total of 1834 pairs were retained for the Delphi surveys, and 608 drug pairs were retained for round 3. Final scoring demonstrated that participants were able to identify pairs where the substitutions represented high risk of harm for receiving the delivered drug in error (eg, did not receive methylphenidate/received methadone), high risk of harm for not receiving the intended drug (eg, did not receive furosemide/received fosinopril), and pairs where the potential harm was high from not receiving the intended drug and from erroneously receiving the delivered drug (eg, did not receive albuterol/received labetalol). CONCLUSIONS: Pediatricians have identified LASA drug substitutions that pose a high potential risk of harm to children. These results will allow future efforts to prioritize pediatric LASA errors that can be screened prospectively in outpatient pharmacies.

Improving pediatrician knowledge about environmental triggers of asthma.

BACKGROUND: Control of environmental triggers (ETs) greatly improves asthma outcomes in children. Disseminating these findings to general pediatricians has not been well established. METHODS: After delivering a structured and standardized presentation on ET identification and control to pediatricians, we surveyed them about knowledge and practices of ET assessment and management. We analyzed matched responses for pre/post and 3- to 6-month follow-up using McNemar's χ(2) test. RESULTS: Matched data were available for 367 participants, and 3- to 6-month follow-up data were available for 83. There was a significant posttraining increase in intention to ask about ETs and recommend ET management. After 3 to 6 months, all responses remained significantly higher than baseline, except "likely to refer to an asthma specialist." CONCLUSION: Pediatricians reported a significant improvement in knowledge about ETs of asthma and a willingness to incorporate exposure history questions and remediation recommendations in their routine practice.

Variation in fruit juice consumption among infants and toddlers: associations with WIC participation.

OBJECTIVES: Juice is a common component of a child's diet. Excessive juice consumption may lead to adverse nutritional and dental outcomes. The objective of the study was to evaluate consumption patterns and parental perception regarding juice in a sample of children from families participating or not participating in Women, Infants, and Children (WIC) services. METHODS: Parents of children aged 12 months to 5 years completed a survey consisting of questions about beverage intake and related opinions. Practices were selected to provide a mix of families who do and do not use WIC services. Comparisons were made by WIC use and by quantity of juice consumption. RESULTS: Of 173 surveys, 51% of participants had received benefits from the WIC program. Overall, children who drank larger quantities of fruit juice drank less milk. One-third of all of the parents who responded to the survey reported that they believed that juice was at least as healthy as fresh fruit, with WIC parents reporting this belief more often (56% vs 9%; P < 0.01) than non-WIC parents. Two-thirds of all of the parents surveyed (66%) introduced juice before their child reached age 12 months, and this was more likely in WIC families (78% vs 54%; P < 0.05). Overall, 81% would prefer to receive fresh fruit as part of the WIC package. CONCLUSIONS: Higher juice consumption is associated with decreased milk consumption. Many parents expressed a belief that juice was at least as healthful as fresh fruit. Being a WIC recipient was associated with an earlier introduction of juice into a child's diet and a greater perception that juice was healthful.

Peripheral intravenous access in pediatric inpatients.

BACKGROUND: Peripheral intravenous (PIV) line placement is a time-consuming procedure performed on the majority of general pediatric inpatients, with significant discomfort to patients. OBJECTIVE: To determine parameters of pediatric PIV placement, including success rates, time to success, and factors associated with success. DESIGN: Prospective study involving direct observation of PIV placement by trained research staff. SETTING: General inpatient wards at 2 medium-sized pediatric hospitals. PATIENTS: Hospitalized children younger than 19 years. RESULTS: Successful placement was achieved in 95.8% (567/592) cases with a median time of 9 minutes. Children younger than 2 years were less likely to have success on the first attempt (38.9% vs 53.5%) and have longer time to success (11 minutes). CONCLUSIONS: Children younger than 2 years experienced lower first-attempt successful PIV placement and took longer. The overall success rate was similar to prior reports; these data are the first to show differential PIV success by patient age.

Improving immunization rates at 18 months of age: implications for individual practices.

OBJECTIVE: We sought to model the effect that a targeted immunization visit at 18 months of age could have on immunization rates of preschool-aged children in a sample of pediatric practices. METHODS: We conducted retrospective chart reviews in six practices of all active patients aged 18-30 months. Up-to-date (UTD) status was defined as receipt of four diphtheria-tetanus-acellular pertussis, three polio, one measles-mumps-rubella, three hepatitis B, and one varicella vaccines. Haemophilus influenza tybe b vaccine was not included due to a shortage in vaccine supply during the time of the study. Practice vaccination rates were determined at 17 months, 18 months, and the age at assessment. Of those not UTD at 17 months, the percentage of children who could be brought UTD with one visit was calculated for each practice. This calculated rate was compared with the measured rate at 18 months of age and at the age of assessment. RESULTS: At each practice, we reviewed 183-616 charts (median = 382). Observed UTD immunization rates at 17 months ranged from 26% to 64% (median = 38%) and increased 3 to 27 percentage points (median = 6) from age 17 months to 18 months and 9 to 39 percentage points (median = 17) from age 17 months to the age at assessment. A simulated vaccination visit at 18 months of age could improve the UTD rates from 27 to 61 percentage points (median = 44). CONCLUSION: Practice-based interventions aimed at encouraging an 18-month well-child visit that emphasizes delivery of vaccines have the potential to substantially increase timely vaccination rates among individual practices.

Do immunisation procedures match provider perception? A study from the South Carolina Pediatric Practice Research Network (SCPPRN).

OBJECTIVE: Immunisation coverage of children by 19 months of age in US primary care practices is below the desired goal of 80%. In order to improve this rate, primary care providers must first understand the specific processes of immunisation delivery within their office settings. This paper aims to identify key components in identifying strategies for quality improvement (QI) of immunisation delivery. METHODS: We surveyed a South Carolina Pediatric Practice Research Network (SCPPRN) representative for each of six paediatric practices. The surveys included questions regarding immunisation assessment, medical record keeping, opportunities for immunisation administration and prompting. Subsequently, research staff visited the participating practices to directly observe their immunisation delivery process and review patient charts in order to validate survey responses and identify areas for QI. RESULTS: Most survey responses were verified using direct observation of actual practice or chart review. However, observation of actual practice and chart review identified key areas for improvement of immunisation delivery. Although four practices responded that they prompted for needed immunisations at sick visits, only one did so. We also noted considerable variation among and within practices in terms of immunising with all indicated vaccines during sick visits. In addition, most practices had multiple immunisation forms and all administered immunisations were not always recorded on all forms, making it difficult to determine a child's immunisation status. CONCLUSIONS: For any QI procedure, including immunisation delivery, providers must first understand how the process within their practice actually occurs. Direct observation of immunisation processes and medical record review enhances survey responses in identifying areas for improvement. This study identified several opportunities that practices can use to improve immunisation delivery, particularly maintaining accurate and easy-to-locate immunisation records and prompting for needed immunisations during sick visits.