An intervention to decrease narcotic-related adverse drug events in children's hospitals.

OBJECTIVES: Narcotic-related adverse drug events are the most common adverse drug events in hospitalized children. Despite multiple published studies describing interventions that decrease adverse drug events from narcotics, large-scale collaborative quality improvement efforts to address narcotic-related adverse drug events in pediatrics have not been described. The purpose of this study was to evaluate collaborative-wide narcotic-related adverse drug event rates after a collection of expert panel-defined best practices was implemented. METHODS: All 42 children's hospitals in the Child Health Corporation of America were invited to participate in the Institute for Healthcare Improvement-style quality improvement collaborative aimed at reducing narcotic-related adverse drug events. A collection of interventions known or suspected to reduce narcotic-related adverse drug events was recommended by an expert panel, with each site implementing >or=1 of these best practices on the basis of local need. Narcotic-related adverse drug event rates were compared between the baseline (December 1, 2004, to March 31, 2005) and postimplementation periods (January 1, 2006, to March 31, 2006) after an a priori-defined intervention ramp-up time (April 1, 2005, and December 31, 2005). Secondary outcome measures included constipation rates and narcotic-related automated drug-dispensing-device override percentages. RESULTS: Median narcotic-related adverse drug event rates decreased 67% between the baseline and postimplementation time frames across the 14-site collaborative. Constipation rates decreased 68.9%, and automated drug-dispensing-device overrides decreased from 10.18% to 5.91% of all narcotic doses administered. CONCLUSIONS: Implementation of >or=1 expert panel-recommended interventions at each participating site resulted in a significant decrease in narcotic-related adverse drug events, constipation, and automated drug-dispensing-device overrides in a 12-month, 14-site children's hospital quality collaborative.

The case against renal dose dopamine in the pediatric intensive care unit.

The use of dopamine for the treatment of renal insufficiency has become a controversial issue. Dopamine exerts its effects on the kidneys through activity on the catecholamine receptors and by its diuretic and natriuretic properties. Utilization of renal dose dopamine to increase renal blood flow has been considered beneficial for preservation of renal function for over 30 years. The hypothesis proposed was that increasing urine volume must indicate improving renal function, particularly in oliguric patients. However, recent clinical trials in adult and pediatric patients have not only failed to demonstrate any benefit, but have also suggested that this therapy may actually have detrimental effects. This article reviews basic pharmacology and physiologic effects and the potential adverse effects of "renal dose dopamine." It also examines the results of clinical trials, in both pediatric and adult patients, that evaluated its usefulness for the treatment of renal insufficiency.