The Persistent Challenge of Understanding Preventable Adverse Drug Events

Adverse drug events (ADEs) are a significant safety risk for hospitalized patients.¹ Medical centers devote considerable resources to quality and safety initiatives aimed at mitigating these events, particularly those that are preventable and/or lead to patient harm. However, the precise nature of these events, their frequency, their severity, and the degree of harm they cause are not well understood, especially in pediatric patients. Although it is well documented that voluntary incident-reporting systems inadequately capture ADEs, consistent measurement approaches and reporting have remained elusive.² 

In this issue of Pediatrics, Gates et al³ review the literature on pediatric preventable adverse drug events (pADEs) published between 2000 and 2017. Their well-designed and thorough article reveals many of the serious challenges facing this area of harm detection. Despite overall harm rates being low, the literature reviewed by the authors is heterogeneous in terms of the frequency of pADEs, and they...