BACKGROUND: Despite the widespread implementation of Tall Man lettering, little evidence exists regarding whether this technique has reduced drug errors due to look-alike sound-alike (LA-SA) drug names. This study evaluated rates of potential LA-SA drug errors in the drug management process through to the point of dispensing before and after implementation of Tall Man lettering in 2007.

METHODS: We used detailed pharmacy data for paediatric inpatients (<21 years old) from 42 children's hospitals in 2004-2012. After prespecifying a set of 8 potential LA-SA drug error patterns we searched within each hospitalisation for the occurrence of one of these patterns for a total of 12 LA-SA drug pairs deemed highly relevant to paediatric inpatients. To assess for potential change of error rates before and after Tall Man lettering implementation, we performed segmented regression analyses for each of 11 LA-SA drug pairs (because 1 pair had no detected potential errors) and for the overall total errors of all 11 LA-SA drug pairs.

RESULTS: Among 1 676 700 hospitalisations, no statistically significant change was detected for either the intercept or the slope of LA-SA error rate for each of the 11 drug pairs or for the combined error rate. In a sensitivity analysis of the moving average of the potential error rate over the entire study period, no downward trend in potential LA-SA drug error rates was evident over any time period 2004 onwards.

CONCLUSIONS: Implementation of Tall Man lettering in 2007 was not associated with a reduction in the potential LA-SA error rate. Whether Tall Man lettering is effective in clinical practice warrants further study.

<p><strong>BACKGROUND: </strong>Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients. This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database.</p>

<p><strong>METHODS: </strong>We assembled a retrospective cohort of pediatric inpatients between 5 and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and non-surgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to 2 days after drug administration.</p>

<p><strong>RESULTS: </strong>Surgical and non-surgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to 2 days after PCA exposure, though these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20-44% lower odds of same day CPR in both surgical and non-surgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients.</p>

<p><strong>CONCLUSION: </strong>In this large pediatric inpatient population, morphine administered via PCA device for surgical and non-surgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.</p>

<p><strong>CONTEXT: </strong>Appropriate use of opioids is essential to manage moderate-to-severe pain in children safely and effectively, yet published guidance regarding opioid treatment for pediatric patients is limited, potentially resulting in excessive variation in opioid use in pediatric patients across hospitals in the U.S.</p>

<p><strong>OBJECTIVES: </strong>The aim was to evaluate hospital variation in opioid use in pediatric inpatients.</p>

<p><strong>METHODS: </strong>Using data from the Pediatric Health Information System and the Premier Perspective Database regarding all pediatric inpatients in 626 hospitals, we examined hospital variation in opioid use and the length of opioid use, adjusting for patient demographic and clinical characteristics and for hospital type (children's vs. general) and hospital patient volume, using multilevel generalized linear regression modeling.</p>

<p><strong>RESULTS: </strong>Overall, 41.2% of all pediatric hospitalizations were exposed to opioids. Among the exposed patients, the mean length of exposure was 4.6 days. Exposure proportion and exposure length varied substantially across hospitals, even after accounting for patient demographic and clinical characteristics, hospital type and hospital patient volume, especially among terminal hospitalizations. For patients discharged alive vs. died, the adjusted exposure percentage for each hospital ranged from 0.7% to 99.1% (interquartile range [IQR]: 35.3%-59.9%) vs. 0.1% to 100.0% (IQR: 29.2%-66.2%), respectively, and the adjusted exposure length ranged from 1.0 to 8.4 days (IQR: 2.2-2.7 days) vs. 0.9 to 35.2 days (IQR: 4.0-7.4 days).</p>

<p><strong>CONCLUSION: </strong>The substantial hospital-level variation in opioid use in pediatric inpatients suggests room for improvement in clinical practice.</p>

<p><strong>BACKGROUND: </strong>The pediatric complex chronic conditions (CCC) classification system, developed in 2000, requires revision to accommodate the International Classification of Disease 10th Revision (ICD-10). To update the CCC classification system, we incorporated ICD-9 diagnostic codes that had been either omitted or incorrectly specified in the original system, and then translated between ICD-9 and ICD-10 using General Equivalence Mappings (GEMs). We further reviewed all codes in the ICD-9 and ICD-10 systems to include both diagnostic and procedural codes indicative of technology dependence or organ transplantation. We applied the provisional CCC version 2 (v2) system to death certificate information and 2 databases of health utilization, reviewed the resulting CCC classifications, and corrected any misclassifications. Finally, we evaluated performance of the CCC v2 system by assessing: 1) the stability of the system between ICD-9 and ICD-10 codes using data which included both ICD-9 codes and ICD-10 codes; 2) the year-to-year stability before and after ICD-10 implementation; and 3) the proportions of patients classified as having a CCC in both the v1 and v2 systems.</p>

<p><strong>RESULTS: </strong>The CCC v2 classification system consists of diagnostic and procedural codes that incorporate a new neonatal CCC category as well as domains of complexity arising from technology dependence or organ transplantation. CCC v2 demonstrated close comparability between ICD-9 and ICD-10 and did not detect significant discontinuity in temporal trends of death in the United States. Compared to the original system, CCC v2 resulted in a 1.0% absolute (10% relative) increase in the number of patients identified as having a CCC in national hospitalization dataset, and a 0.4% absolute (24% relative) increase in a national emergency department dataset.</p>

<p><strong>CONCLUSIONS: </strong>The updated CCC v2 system is comprehensive and multidimensional, and provides a necessary update to accommodate widespread implementation of ICD-10.</p>

<p><strong>BACKGROUND: </strong>Pediatric palliative care (PPC) improves the quality of life for children with life-limiting conditions, but the cost of care associated with PPC has not been quantified. This study examined the association between inpatient cost and receipt of PPC among high-cost inpatients.</p>

<p><strong>METHODS: </strong>The 10% most costly inpatients treated at a children's hospital in 2010 were studied, and factors associated with receipt of PPC were determined. Among patients dying during 2010, we compared 2010 inpatient costs between PPC recipients and nonrecipients. Inpatient costs during the 2-year follow up period between PPC recipients and nonrecipients were also compared. Patients were analyzed in 2 groups: those who died and those who survived the 2-year follow-up.</p>

<p><strong>RESULTS: </strong>Of 902 patients, 86 (10%) received PPC. Technology dependence, older age, multiple chronic conditions, PICU admission, and death in 2010 were independently associated with receipt of PPC. PPC recipients had increased inpatient costs compared with nonrecipients during 2010. Among patients who died during the 2-year follow-up, PPC recipients had significantly lower inpatient costs. Among survivors, PPC recipients had greater inpatient costs. When controlling for patient complexity, differences in inpatient costs were not significant.</p>

<p><strong>CONCLUSIONS: </strong>The relationship of PPC to inpatient costs is complex. PPC seems to lower costs among patients approaching death. Patients selectively referred to PPC who survive most often do so with chronic serious illnesses that predispose them to remain lifelong high-resource utilizers.</p>

<p><strong>OBJECTIVE: </strong>To describe the use of opioids and sedatives to pediatric patients dying in the hospital in the 2 weeks preceding death.</p>

<p><strong>STUDY DESIGN: </strong>We conducted a retrospective study on opioid and sedation medication exposure among children who die in hospitals in the US by using large administrative data sources. We described patterns of exposure to these medications for deceased inpatients (&lt;21 years of age) between 2007 and 2011 (n = 37,459) and factors associated with the exposure. Multivariable logistic regression models were used to estimate the ORs.</p>

<p><strong>RESULTS: </strong>Overall, 74% patients were exposed to opioids or sedatives in the 14 days before death. Among patients with 6 or more hospital days before death, the daily exposure rate ranged from 73% (the sixth day before death) to 89% (the day of death). The most commonly used medications were fentanyl (52%), midazolam (44%), and morphine (40%). Older age (ORs 1.6-3.7), black race (ORs 0.8), longer hospital stay (ORs 6.6-9.3), receiving medical interventions (including mechanical ventilation, surgery, and stay in the intensive care unit, ORs 1.7-2.6), having comorbidities (ORs 1.7-2.4), and being hospitalized in children's hospitals (ORs 4.0-4.5) were associated with exposure of opioid and sedation medication on adjusted analysis.</p>

<p><strong>CONCLUSION: </strong>Although most pediatric patients terminally hospitalized are exposed to opioid and sedation medication, some patients do not receive such medications before death. Given that patient and hospital characteristics were associated with opioid/sedative exposure, these findings suggest areas of potential quality improvement and further research.</p>

BACKGROUND AND OBJECTIVES: Hospitalized infants, children, and adolescents are typically exposed to numerous distinct medications during inpatient admissions, increasing their risk of potential drug-drug interactions (PDDIs). We assessed the prevalence and characteristics of PDDI exposure of pediatric patients treated in children's hospitals.

METHODS: This retrospective cohort study included patients <21 years old hospitalized in children's hospitals throughout the United States. PDDIs were identified by using the MicroMedex DRUG-REAX system. We calculated the patients exposed to PDDIs, stratified according to the seriousness of the interaction; daily and cumulative counts of PDDI exposures; and characterization of the cited potential adverse effects.

RESULTS: Of 498 956 hospitalizations in 2011, 49% were associated with ≥1 PDDI, with a "contraindicated" PDDI occurring in 5% of all hospitalizations, a "major" PDDI present in 41%, a "moderate" PDDI in 28%, and a "minor" PDDI in 11%. Opioids were involved in 25% of all PDDIs, followed by antiinfective agents (17%), neurologic agents (15%), gastrointestinal agents (13%), and cardiovascular agents (13%). One-half of all PDDI exposures were due to specific drug pairs occurring in ≤3% of patients per hospital day. The most common potential adverse drug events included additive respiratory depression (in 21% of PDDIs), bleeding risk (5%), QT interval prolongation (4%), reduced iron absorption/availability (4%), central nervous system depression (4%), hyperkalemia (3%), and altered diuretic effectiveness (3%).

CONCLUSIONS: Exposure to PDDIs is common among hospitalized children. Empirical data are needed to determine the probability and magnitude of the actual harm for each specific PDDI, particularly for less common drug pairs.