Previous research has shown that patients receiving treatment in EDs are at particularly high risk for experiencing medication errors because of the acute nature of presenting illnesses, the chaotic environment, and the lack of oversight to verify medication orders and administration, among other reasons. For children, the risk of medication errors is heightened because weight-based drug dosing practices are common in this patient population. In addition, many healthcare providers have limited experience with pediatric prescribing and pharmacotherapy. Several studies have suggested that physician prescribing is the most common source of medication errors among children and in EDs.
Physicians practicing in rural areas face distinct disadvantages when caring for seriously ill or injured pediatric patients. “Several factors can contribute to the increased risk of medication errors in children receiving care in rural EDs,” explains James P. Marcin, MD, MPH. “These may include issues relating to physician experience and specialized training as well as infrastructural factors.”
The Role of Telemedicine
To address shortcomings, telemedicine is increasingly being used as an alternative to telephone consultations for providing pediatric specialty consultations to children presenting to rural and underserved EDs throughout the United States. “Telemedicine has the potential to prevent medication errors that result from the lack of access to experienced staff and pediatric specialty expertise,” says Dr. Marcin. “Research has shown that having specialists treat children can lower risks of medication errors.” He notes, however, that although telemedicine has been proposed as a potential solution, few data support its clinical effectiveness and its effect on medication errors.
A Closer Look
In a study published in Pediatrics, Dr. Marcin and colleagues evaluated whether pediatric telemedicine consultations were associated with fewer physician-related medication errors among seriously ill and injured children presenting to rural EDs. “We wanted to see how telemedicine consultations impacted medication error rates when compared with telephone consultations or no consultations at all,” Dr. Marcin says.
The study team conducted retrospective chart reviews on 234 seriously ill and injured children presenting to eight rural EDs that had access to pediatric critical care physicians from an academic children’s hospital. All eight hospitals were provided telemedicine services, high-resolution cameras, monitors, and secure telecommunication connections to facilitate the consultations. In addition, pediatric critical care specialists were made available around-the-clock toprovide consults.
According to the results, patients who received telemedicine consultations had significantly fewer physician–related drug errors than those who received telephone consultations or no consultations (Table 1). The most common errors were incorrect doses, and telemedicine patients had far fewer dosage errors. Furthermore, in multivariable analyses that adjusted for clustering at the patient level, patients receiving telemedicine consultations were less likely to have physician-related ED drug errors than those receiving telephone consultations and no consultations (Table 2). This lower incidence of errors was identified despite children being younger in the telemedicine cohort than in the other cohorts.
“Telemedicine has the potential to prevent medication errors that result from the lack of access to experienced staff and pediatric specialty expertise.”
“Our results clearly show that using telemedicine to increase specialist presence lowers the risk of medication errors among seriously ill children,” says Dr. Marcin. “Notably, the contrast between telemedicine and telephone error rates appears to indicate that visual interaction is a key component to improving care.” He adds that the findings could be attributed to the fact that telemedicine helps enable physicians to conduct better assessments and therapeutic recommendations together with specialists who are experienced in the care of seriously ill and injured children.
Dr. Marcin says his study team’s findings could have a significant impact on care for all patients. “Everybody wins when specialists can be teamed with other clinicians,” he says. “Actually seeing the patient can empower specialists and rural providers to deliver a higher level of care in their community.” The observed reduction in medication errors with telemedicine can also potentially improve health outcomes and lower healthcare costs. Telemedicine may serve as a means to enhancing patient access to specialists and increasing safety for children receiving emergency care in rural, underserved hospitals.
“Most EDs throughout the country do not use telemedicine unless the technology is used for stroke care,” says Dr. Marcin. “However, as telecommunications continue to improve, it’s hoped that barriers to telemedicine use will be overcome and that more hospitals will invest in these models. Our research adds to the growing body of evidence that telemedicine can have a significant impact on quality of care and safety. It also has the potential to improve patient and provider satisfaction while reducing healthcare costs.”
Readings & Resources (click to view)
Dharmar M, Kuppermann N, Romano PS, et al. Telemedicine consultations and medication errors in rural emergency departments. Pediatrics. 2013;132:1090-1097. Available at: http://pediatrics.aappublications.org/content/early/2013/11/19/peds.2013-1374.abstract.
Selbst SM, Levine S, Mull C, Bradford K, Friedman M. Preventing medical errors in pediatric emergency medicine. Pediatr Emerg Care. 2004;20:702-709.
Rinke ML, Moon M, Clark JS, Mudd S, Miller MR. Prescribing errors in a pediatric emergency department. Pediatr Emerg Care. 2008;24:1-8.
Galli R, Keith JC, McKenzie K, Hall GS, Henderson K. TelEmergency: a novel system for delivering emergency care to rural hospitals. Ann Emerg Med. 2008;51:275-284.
Duchesne JC, Kyle A, Simmons J, et al. Impact of telemedicine upon rural trauma care. J Trauma. 2008;64:92-97.