Cincinnati Children’s Participates in National Collaborative Decreasing Narcotic-Related Adverse Drug Events

Monday, January 01, 0001

Cincinnati Children’s Hospital Medical Center is one of 14 children’s hospitals in the United States in a collaborative quality improvement effort that has resulted in a demonstrated decrease in narcotic-related adverse drug events.

The results of the study will be published in the October issue of Pediatrics, the journal of the American Academy of Pediatrics.

Narcotics are high risk medications with many side effects. Approximately 41 percent of all inpatients receive at least one dose of a narcotic. Nor surprisingly, narcotic-related ADEs are the most common ADEs in hospitalized children: A bit greater than one in 10 children have a chance of an adverse drug event; as many as half of all pediatric drug events are caused by narcotics.

Led by the Child Health Corporation of America, 14 of the 42 CHCA children’s hospitals came together to try to reduce narcotic-related ADEs. The organizations selected four primary areas for active collaboration: Constipation, known to be a frequent narcotic-associated ADE. This was addressed by recommending routine, proactive use of laxatives and stool softeners when narcotics are prescribed.

Overrides of automatic medication dispensing devices, known to increase the risk of errors, were targeted with limits on override opportunities.

Withdrawal symptoms, a significant ADE, were targeted for improvement with a standardized weaning protocol.
ADEs that occur at the high-risk transfer process were addressed by recommending consistent medication reconciliation strategies.

Using the Institute for Healthcare Improvement’s quality improvement model, the 14 hospitals used small tests of change between April 1, 2005, and March 31, 2006, to determine which changes resulted in improvement.
The interventions that were implemented resulted in a 67 percent reduction in narcotic-related ADEs, indicating that the recommended changes can significantly improve patient outcomes. Constipation rates decreased by 68.9 percent and automated drug-dispensing overrides decreased from 10.18 percent to 5.91 percent of all narcotic doses administered.

The pediatric-specific, evidence-based change practices are now available to any hospital interesting in reducing pediatric ADE rates at

Cincinnati Children’s participation in the study was led by Joe Luria, M.D., medical director of the emergency department, and Tamara Hutson, a pharmacist at Cincinnati Children’s. The study was funded by a grant from the Agency for Healthcare Research and Quality.

Cincinnati Children's Hospital Medical Center is one of America’s top three children’s hospitals for general pediatrics and is highly ranked for its expertise in digestive diseases, respiratory diseases, cancer, neonatal care, heart care and neurosurgery, according to the annual ranking of best children's hospitals by U.S. News & World Report. One of the three largest children’s hospitals in the U.S., Cincinnati Children’s is affiliated with the University of Cincinnati College of Medicine and is one of the top two recipients of pediatric research grants from the National Institutes of Health.

For its achievements in transforming healthcare, Cincinnati Children's is one of six U.S. hospitals since 2002 to be awarded the American Hospital Association-McKesson Quest for Quality Prize® for leadership and innovation in quality, safety and commitment to patient care. The hospital is a national and international referral center for complex cases, so that children with the most difficult-to-treat diseases and conditions receive the most advanced care leading to better outcomes.

Contact Information

Jim Feuer, 513-636-4656,