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Adverse Drug Events

Rolling 12 month average

Mouse or hover over lines for monthly data.



Adverse Drug Events (ADE)

What is it?

Adverse drug events are errors that occur related to medications that cause harm to a child.   Children’s medications are usually dosed by weight which adds an additional level of complexity to the ordering and delivery of medications.

Why is it important?

Underdosing, overdosing or giving the wrong medication to a child can potentially have serious consequences.

How do we measure it?

We follow a metric called the "rolling average," which is calculated by adding the number of adverse side effects over the previous 12 months and dividing by 12. Each point on the graph represents the average of the 12 months preceding it. In other words, for June 2016, we add all the adverse side effects from July 2015 through June 2016 and divide by 12. This is the data point that's represented on the graph for June.

What are we doing to improve?

  • We are part of a national collaborative called the Children’s Hospital Solutions for Patient Safety (CHSPS) in which hospitals share ideas and data and work together to decrease the number of adverse drug events nationwide.
  • We use a computerized order entry system for physicians and a pharmacist and nurse check all orders.
  • Our pharmacy team investigates all medication errors with a focus on constantly improving our process.
  • We report all medication errors regardless of whether they cause harm to a patient.