Medication Safety in Critically Ill Children Timothy S. Lesar, PharmD,* Amy Mitchell, PharmD,y Patrick Sommo, PharmDz Medication safety is a primary component of a comprehensive safety program and an integral part of quality patient care. Effective and consistent implementation of safe medication practices is a complex and difficult task. Leadership, adequate resources, cultural change, adherence to proven safety processes, application of technologic advances, improved caregiver skills, and increased patient and family involvement are among the keys to improving medication safety. This article provides an overview of medication errors and safety strategies in critically ill pediatric patients. Clin Ped Emerg Med 7:215-225 ª 2006 Elsevier Inc. All rights reserved. KEYWORDS pediatric adverse drug events, medication error, pediatric emergency care D eficiencies and difficulties in the use of medications are a well-recognized cause of preventable patient harm [1-7]. The use of medications is a primary component of the care of critically ill children. The drug therapies used are typically complex and carry significant potential for producing adverse events. Wide variation in patient size, preexisting health status, lack of stand- ardized dosage forms, drug administration challenges, and the need for dosage calculations create additional risks [7-37]. Safe and optimal delivery of drug therapies to critically ill patients requires a planned and compre- hensive medication use system [6-9,38-89]. Importantly, to safely function in such a system, all caregivers must have a working understanding of the potential harm from medications and how safe medication practices reduce risk to our patients. Medication safety is a primary component of a comprehensive safety program and an integral part of quality patient care. Subtle and sometimes unrecognized deficiencies in quality of care are thought to contribute to considerably more preventable adverse drug events (ADEs) than frank and obvious errors in care, but it is often difficult for individual caregivers to recognize a cause-and-effect relationship. For example, a pharmacist processing a large number of medication orders in the pharmacy may not recognize the critical need for timely delivery of a specific medication that a nurse is depending on. In many cases, poor patient outcomes are attributed to patient characteristics rather than subtle deficiencies or errors in the provision of care. Demonstrating the relationship between care quality and outcomes is difficult, but a number of studies have shown that medication errors and deficiencies in quality of care occur frequently in critically ill children, all too often leading to considerable avoidable patient harm [7-21]. Effective and consistent implementation of safe med- ication practices is a complex and difficult task. Leader- ship, adequate resources, cultural change, adherence to proven safety processes, application of technological advances, improved caregiver skills, and increased patient and family involvement are among the keys to improving medication safety [6,13,16,17,49]. This article provides an overview of medication errors and safety strategies in critically ill pediatric patients. 1522-8401/$ - see front matter ª 2006 Elsevier Inc. All rights reserved. 215 doi:10.1016/j.cpem.2006.08.009 *Director of Pharmacy, Albany Medical Center, Albany, NY. yClinical Pharmacy Specialist—Children’s Hospital at Albany Medical Center, Albany, NY. zPharmacist—Children’s Hospital at Albany Medical Center, Albany, NY. Reprint requests and correspondence: Timothy S. Lesar, PharmD, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208. Tel.: +1 518 262 3255; fax: +1 518 262 4123. (E-mail: lesart@mail.amc.edu)