Purpose To evaluate the validity and reliability of select recommended triggers, defined as flags found on review of the medical record that prompt further investigation to determine the presence or absence of an adverse drug event (ADE), selected from a list initially constructed based on severity, frequency, and detectability of triggers within a pediatric population. Methods This was a single-center, retrospective cohort analysis of pediatric patients admitted to University of North Carolina (UNC) Children’s Hospital who received trigger-associated medications between January 2015 and December 2016. Patient-care areas of the emergency department, operating rooms, and post-anesthesia care units were excluded. Trigger-detection encounters were evaluated by two reviewers using pre-established, consensus ADE criteria as determined by a panel of pediatric and medication safety specialists at UNC Medical Center. Events were categorized according to medication-related trigger and analyzed using descriptive statistics. Results A total of 3,836 positive triggers were included in this study. For the aggregate 12-part trigger tool package, 1,055 positive ADEs were identified, leading to a positive predictive value (PPV) of 27.5%. A 50% increase from baseline serum creatinine, resulting from co-administration of 2 or more nephrotoxic medications accounted for a total of 3,698/3,836 (96.4%). Incomplete documentation was the leading cause for event exclusion, 8/27 (30%). The triggers with the highest PPV included protamine 4/4 (100%), flumazenil 1/1 (100%), and vancomycin-related events 51/67 (76.1%), respectively. Phenytoin level >30 µg/mL or free level >2.5 µg/mL resulted in the lowest PPV, 1/12 (8.3%). Conclusion This study lays the foundation for further studies to develop a robust pediatric trigger tool that may involve developing multi-element triggers, determining sensitivity and specificity of triggers, or mobilizing the trigger tool to an automated system. Trigger tools can be individualized to meet each institutions’ needs and unique patient population.

Background: The challenge of addressing variation in practice is underlined by variation in institutional operational and financial limitations, which ultimately directs institutional insulin dispensing strategy. Insulin therapy is multi-modal, and inpatient pharmacies may be responsible for simultaneously managing up to 8 formulations. While available as a tool for glycemic management in the inpatient setting, intravenous (IV) insulin and insulin pumps are out of scope for this review. Considerations when designing subcutaneous insulin dispensing processes include medication safety, infection control, pharmacy workflow, nursing workflow, drug cost, hardware cost, and hospital policy. Objective: This review provides an overview of common inpatient subcutaneous insulin dispensing practices, describes the regulations directing current practice, and discusses the benefits and risks of each dispensing practice. Finally, the review provides recommendations for subcutaneous insulin dispensing practices with respect to institutional limitations that minimize patient safety risk and consider the variable costs that practices incur. Methods: Common formulations will be presented along with medication safety considerations and potential medication administration errors to preface strategies for management. Conclusion: Nearing the centennial anniversary of the invention of insulin, the practice of dispensing subcutaneous insulin products has remained a core responsibility of the hospital pharmacy as a primary treatment option for Diabetes Mellitus. Despite the continued presence of this product as a universal component of the hospital formulary, subcutaneous insulin dispensing practices remain varied institution-to-institution.