Safety Culture: Medication Adverse Event Tracking at a Pediatric Oncology Hospital in Guatemala

Saturday, 29 July 2017

Liliana Zelaya, BSN
Emily Dray, MSN
Medical Surgical Intensive Care Unit, Boston Childrens Hospital, Boston, MA, USA


The ECHO Project: Educacion de Cuidados Intensivos en un Hospital de Oncologia is a multidisciplinary educational collaborative between the Medical-Surgical Intensive Care Unit at Boston Children’s Hospital and Unidad Nacional de Oncologia Pediatric (UNOP). The initial goal of the partnership was to facilitate the development of an acute care nursing orientation and continuing education curriculum for the hospital and has grown to encompass other strategic goals. In January of 2016 the ECHO Project team, consisting of two Boston Children’s Staff Nurses and two Boston Children’s Clinical Pharmacists, traveled to Guatemala for a quarterly site visit. The goals for this visit were to perform an assessment of pharmacy systems and evaluate processes already in place to ensure medication safety. The assessment uncovered the need for a comprehensive medication adverse event tracking system in the context of unknown error frequency or classification.

The Harvard Medical Practice Study demonstrates that medication errors are the most frequent type of medical adverse event; it is for this reason that we chose to focus on medication event tracking (Kaushal et al., 2004). It is well delineated in the literature that adverse drug events are preventable. Pediatric patients are a high risk group when it comes to medication adverse events for several reasons, including, but not limited to: weight-based dosing, dilutions to stock medications are needed to create appropriate dosing, and wide variations in organ function (Kaushal et al., 2004). Pediatric cancer patients are at especially high risk due to the potential for both toxicity and treatment failure with medication errors (Oberoi, Trehan, & Marwaha, 2014). There is a paucity of literature with regard to medication error rates among pediatric oncology patients, especially in low resources settings. This quality improvement project will contribute to the knowledge base while at the same time directly impacting the quality of patient care. The creation of safer systems has the potential to improve patient outcomes and decrease morbidity and mortality.


Using the Plan-Do-Study-Act method for quality improvement we will implement a hospital-wide medication adverse event tracking system in collaboration with a multidisciplinary team of Boston Children’s Hospital experts and UNOP leaders.

  • Identify key stakeholders at UNOP and at BCH to define the project team and leaders. Engagement of hospital leadership at UNOP.

  • Perform a literature review to determine existing evidence on medication error frequency and tracking systems in low resource hospital settings.

  • Design a reporting form that is easily accessible to all staff and user friendly.

  • Design and implement Medication Adverse Event Tracking training for all levels of hospital staff.

  • Tracking of medication adverse events to identify system strengths and weaknesses.

  • Multidisciplinary root cause analysis to assess findings and implement changes based on institutional needs, resources, and limitations.

Results: Project continues to be ongoing.


Medication errors are a global health care issue and in low-resource settings there is a lack of infrastructure to support non-punitive identification and correction of systems errors that contribute to medication adverse events. This quality improvement project takes a systems approach to medication adverse events to identify medication error frequency, define systems strengths and weaknesses, and promote solutions to increase patient safety and reduce nursing and/or pharmacy workload. Collaboration with our colleagues at UNOP is essential to design a successful and sustainable system that meets institutional standards and needs.