原文: Caution: The Hospital May be Hazardous to Your Child's Health

It's my third and final year of being a pediatric resident. I'm the supervisor of the interns on the inpatient ward and we are at morning "x-ray rounds." My intern urgently grabs my arm, drags me to the back of the room and, ashen-faced, says "I think I just ordered 10 times the dose of insulin for Bobbi that I should have."

Let me explain. Because of her short stature, Bobbi is undergoing a "growth hormone stimulation test," in which we purposely give her a low dose of insulin to see if it will stimulate the normal production of growth hormone. Ten times the recommended dose will lead to dangerously low blood sugar levels which, among other things, could cause brain damage, even death to this happy, healthy, normal, short kid.

We race up three flights to the inpatient floor. I grab a syringe full of concentrated sugar (glucose) and barge into her room where, to our great relief, she is chatting comfortably with her father, an attorney who - I am not making this up - sues doctors for malpractice.

I infuse her IV with the glucose, all the time asking her "How do you feel...How do you feel?"

"Anything wrong?" her father asks with just a touch of concern.

"Oh, no," I say, breezily. "Just a routine part of the test."

Having calculated the dose of sugar need to offset the overdose of insulin, she remains blessedly conscious and oblivious to my terror. Her blood sugar eventually dips only a little and the test is completed uneventfully.

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Scary. I still have nightmares about it, all these years later.

But, as a new article in the journal Pediatrics shows, apparently this is still not all that unusual. These researchers carefully looked at the medical records of kids admitted to 12 different Children's Hospitals. They found that about 7.3% (1 in 14 kids) experienced an "adverse drug effect" (ADE) of some sort (mostly a drug side effect). By the way, the most common medications causing ADEs were pain killers (50%) and antibiotics.

OK, 1 in 14 is a lot but before you panic, let's do the math:

1. Keep in mind that 13 of 14 (93%) had no reported problems of any kind with medications.
   
2. Of the 7% who experienced problems, 97% were 'mild and temporary.'
   
3. Of those 7%, 1 in 5 was felt to have been "preventable."
   
4. That works out to 1 in 70 hospitalized children who will experience a medication error of some kind, which is way, way too high (and this probably underestimates the problem because some are never reported).
   
   

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Why do we make medication errors?

I could be flippant and say it's because we're human and that would be partly right. Also, I think it's easier to make a dosage error with children because the amount of medication given is often calculated on a "per weight" basis. That means the dose of a common medication could vary 50 fold between prescribing it for a 4 pound premature infant and a 200 pound teenager. So it's easier to get confused and harder to spot the error.

Additionally, there is the old "look alike/sound alike" mistake, whereby the pharmacist substitutes one medication (e.g., hydralazine) for another (hydroxyzine), either through my error or illegibility in writing it or the pharmacist's error in reading it.

But I've seen in my own hospital that most errors can be prevented by recognizing to err is human and by implementing appropriate safeguards to prevent us from screwing up. In my hospital, for example, all medication prescriptions are run through the computer to be sure the dose is in the usual range (and not, for example, the most common 'factor of 10 mistake' of my intern) and to warn of potential drug-drug interactions. Additionally, nurses check and double check that the dose ordered is the dose given, and that the right patient is getting the right meds.

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I'd like to empower you to play an active role in preventing medication errors to your (and others') children. Here's what you can do:

In the pediatric office:

1. Look at and review all prescriptions written by your pediatric provider.
   
2. Be sure the Rx is easily legible and clearly written.
   
3. Read it aloud to your pediatric provider.
   
4. Ask if the dose is the usual dose.
   
5. Ask your pediatric provider what hospital precautions are in place to prevent medication errors.

If your child is in the hospital:

1. Ask the staff the same question about procedures for preventing medication errors.
   
2. Look at all medications being administered to your child.
   
3. Be sure your child's name is on it.
   
4. Ask the nurse if the dose is the usual (if you're very ambitious check out all doses on the web to be sure they are in the normal range).

Will you be perceived as a pain in the butt by the medical staff? Absolutely, but, I hope, in a good way. After all, we all need to work together to ensure the inexcusable doesn't occur even one in a million times.

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译文: 警告：医院可能给您孩子的健康带来损害

       这是我作为儿科住院大夫的第三年，也是最后一年。当时我是住院部实习医生的导师，一天早晨，我们正在做“X-射线房”例行查房，突然,我手下的一名实习医生急切地抓住我的胳膊，把我拽到屋后，脸色苍白地对我说:“我想起了，刚才给孩子注射胰岛素的量是本应注射量的十倍。”

      让我解释一下，那个孩子因为身材矮小，正在接受“生长激素刺激试验”。在这个试验中，我们想通过给她注射低剂量的胰岛素来得知是否能产生正常的生长激素。注射推荐剂量的十倍将会导致低血糖发生，低血糖可能会给这个快乐、智力正常、矮个子小孩带来脑损坏、甚至引起死亡的危险。

      冲上三楼的住院部，我夺过一只装满了浓缩糖（葡萄糖）的注射器闯入她的房间，令我欣慰的是，她正和她的父亲（一名律师）聊天呢-我还没来得及想那名律师-控告医生玩忽职守的情形。

      我把葡萄糖输进她的静脉中，不断问她“感觉怎么样.....你感觉怎么样？”

      “有什么不对吗？”她的父亲略带关切地询问。

      “哦，没什么”我带着轻松的口气，说：“只是试验的一个部分”。

     当我 计算好抵消胰岛素所需葡萄糖的剂量时，她仍保持很清醒，没在意我的恐惧。她的血糖只是稍低一点，试验最终平安完成。

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      心慌。这么多年过去，我仍心有余悸。

      但是，做为杂志儿科展中的一篇新文章，仍然具有不同寻常的反响。这些研究人员查看了送入12个不同儿童医院治疗的孩子病历卡，发现大约7.3%（14个孩子中有一个孩子）的孩子某种程度上发生过experienced an "adverse drug effect"(ADE)（多数是药物副作用）。顺便说一下，大多数引起不良反应（ADE）的药物是止痛药（50%）和抗生素。

      好了，1/14是一个很大的数字，但在引起你恐慌之前，让我们算一下：

      紧记13/14（93%）进行药物治疗的孩子发生用药失误没有报导。

      7%的孩子有问题，97%的孩子问题“轻微或暂时性”的。

      其中7%的那些孩子，1/5的用药失误可“挽回”。

      那就算出70个住院治疗的孩子中有1个，将要经历某种用药失误，失误率很高（因为一些医疗事故从未报道，可能还估计低了。）

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      为什么我们会发生用药失误？

      我说因为我们是人类，只有部分正确，可能有点轻率。我想儿童易造成用药剂量失误，这是因为儿童的给药剂量是根据“单位重量”来计算的。这既意味着在4英镑重的未成熟婴儿和200英镑青少年之间，开具普通药物用药剂量会有50折不同。所以很容易造成混乱，也很难发现失误。

      另外，也有许多经常发生的“看起来相似/听起来相似”的过失，那就是为何会发生药剂师用一种药物（例如肼苯哒嗪）代替另一种药物（羥嗪），或者发生我那样的失误或illegibility in writing(字迹模糊不清）或者药剂师看错字的现象。

      但是在我的医院，我已经了解到只要人们认识到人非圣贤，孰能无错这一道理并采取适合的安全措施，保持振作状态，大多数失误是可以避免的。在我的医院，所有的药物处方都被输进计算机中，以确保剂量在正常的范围并且写出药物相互作用的警告。另外，护士核对、复核所开的剂量与所给的剂量是否一致，病人是否与所开药方相匹配。  

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      我希望你能对自己的孩子或别人的孩子在预防用药失误上起到积极作用。下面是你能做到的：

在儿科办公室office:

查看和检查儿科大夫开具的所有处方。

确保处方容易辨认和清晰。

大声朗读给你的儿科大夫。

询问剂量是否正常。

适时询问你的儿科大夫医院用来防止用药失误的防范措施是什么。

如果你的孩子在医院:

询问医务工作者关于预防用药失误程序同样的问题。

查看给孩子的所有药物。

确信上面孩子的名字。

询问护士剂量是否正常（如果你有信心，请在网上查出所有的剂量确保它们在正常的范围之内）。

       你是否注意到可能成为医务人员的笑柄？绝对能，但希望情形好些。毕竟，我们共同努力确保失误不发生，哪怕只是百万分之一。

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文章选自：

“开发，测试，和发现一种儿科关注的触发工具来识别美国儿童医院与药物相关的危害。”

Takata G,et al.Pediatrics, April 2008

http://pediatrics.aapublications.org/cgi/content/full/121/4/e927