A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center.

BACKGROUND: Adult trauma centers are major providers of medical management for pediatric trauma patients in the United States. Medication administration in this patient population is complex and fraught with potential error. METHODS: We designed a multidisciplinary team consisting of a pediatric hospitalist, pediatric care coordinator, pediatric nurse, pharmacist, and the trauma service to manage pediatric trauma patients from admission until discharge. The team mandated collective decision making for medication dosing and administration, weight documentation, and implemented a medication error reporting system. Our goal was to derive and implement a multidisciplinary practice and education-based model of pediatric trauma patient care to identify and decrease adverse medication events. RESULTS: Two hundred fifty-nine pediatric trauma patients were studied from January 1, 2003 to December 31, 2004, 125 pre-team implementation (control group) and 134 post-team implementation (study group). There were no significant differences in age, sex, mechanism of injury, injury severity score, or hospital length of stay between groups. There were significant reductions in number of medication prescribing errors (25 vs 15 errors; P = 0.05) and number of medication administration errors (19 vs 9 errors; P = 0.05) in the study group. Weight documentation improved significantly in the study group (90% vs 81%; P = 0.048). CONCLUSIONS: Instituting a multidisciplinary approach to pediatric trauma patient care is practical and can significantly decrease adverse medication events.

A protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy.

Trauma patients on prescribed warfarin therapy sustaining intracranial hemorrhage can be difficult to manage. Rapid normalization of coagulopathy is imperative to operative intervention and may affect outcomes. To identify and expedite warfarin reversal, we designed a protocol to administer a prothrombin complex concentrate. A Proplex T protocol was instituted in May 2004. It dictated that trauma patients with an International Normalized Ratio (INR) greater than 1.5, history of prescribed warfarin therapy, and intracranial hemorrhage on CT scan receive a prothrombin complex concentrate for reversal of their coagulopathy. Neither the protocol nor the factor concentrate was validated for use in this subset of trauma patients; therefore, adherence to the protocol and use of the factor concentrate was not mandatory. Patients not administered the prothrombin complex concentrate received vitamin K and fresh-frozen plasma. The protocol resulted in an increased number of patients receiving Proplex T (54.3% vs 35.4%, P = 0.047). Protocol patients had improved times to normalization of INR (331.3 vs 737.8 minutes, P = 0.048), number of patients with reversal of coagulopathy (73.2% vs 50.9%, P = 0.026), and time to operative intervention (222.6 vs 351.3 minutes, P = 0.045) compared with control subjects. There were no differences in intensive care unit (ICU) days, hospital days, or mortality. The Proplex T protocol increased the number of patients who received prothrombin complex concentrate, provided rapid normalization of INR, and improved time to operative intervention.