Opioid prescription practices for patients discharged from the emergency department with acute musculoskeletal fractures

ABSTRACTBackgroundOpioid related mortality rate has increased 200% over the past decade. Studies show variable emergency department (ED) opioid prescription practices and a correlation with increased long-term use. ED physicians may be contributing to this problem. Our objective was to analyze ED opioid prescription practices for patients with acute fractures.MethodsWe conducted a review of ED patients seen at two campuses of a tertiary care hospital. We evaluated a consecutive sample of patients with acute fractures (January 2016–April 2016) seen by ED physicians. Patients admitted or discharged by consultant services were excluded. The primary outcome was the proportion of patients discharged with an opioid prescription. Data were collected using screening lists, electronic records, and interobserver agreement. We calculated simple descriptive statistics and a multivariable analysis.ResultsWe enrolled 816 patients, including 441 females (54.0%). Most common fracture was wrist/hand (35.2%). 260 patients (31.8%) were discharged with an opioid; hydromorphone (N = 115, range 1–120 mg) was most common. 35 patients (4.3%) had pain related ED visits <1 month after discharge. Fractures of the lumbar spine (OR 10.78 [95% CI: 3.15–36.90]) and rib(s)/sternum/thoracic spine (OR 5.46 [95% CI: 2.88–10.35)] had a significantly higher likelihood of opioid prescriptions.ConclusionsThe majority of patients presenting to the ED with acute fractures were not discharged with an opioid. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Overall, there were few return to ED visits. We recommend standardization of ED opioid prescribing, with attention to limiting total dosage.

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LO26: Are ED physicians contributing to the opioid epidemic?

CJEM ◽

10.1017/cem.2019.69 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S16

Author(s):

G. Mok ◽

H. Newton ◽

L. Thurgur ◽

I. Stiell

Keyword(s):

Tertiary Care ◽

Primary Outcome Measure ◽

Care Hospital ◽

Opioid Epidemic ◽

Opioid Use ◽

Total Dosage ◽

Opioid Prescription ◽

Prescription Practices ◽

Median Dosage ◽

Potential Abuse

Introduction: There is an opioid epidemic which has seen an increased mortality rate of 200% related to opioid use over the past decade. Prescription practices amongst ED physicians may be contributing to this problem. Our objective was to analyze ED physician prescription practices for patients discharged from the ED with acute fractures. Methods: We conducted a health records review of ED patients seen at two campuses of a tertiary care hospital with total annual census of 160,000 visits. We evaluated a consecutive sample of patients with acute fractures (January 1 2016–April 15 2016) seen and discharged by ED physicians. Patients admitted to hospital or discharged by consultant services were excluded. The primary outcome measure was the proportion of patients discharged with an opioid prescription. We collected data using a screening list, review of electronic records, and interobserver agreement for measures. We calculated simple descriptive statistics and estimated 4 months would be required to enroll 250 patients receiving opioid prescriptions. Results: We enrolled 816 patients, with 442 females (54.2%), median CTAS score of 3, and median pain score at triage of 6/10. The most common fractures were wrist/hand (35.2%) and foot excluding ankle (14.8%). An ED pain directive was used at triage for 21.2% and 281 patients (34.4%) received an opioid during ED stay, with tramadol (21.2%) being the most common. Overall, 250 patients (30.6%) were discharged with the following opioid prescriptions and median total dosages: hydromorphone (N = 114, median dosage 23mg, range 1–120mg), tramadol (N = 86, 1000mg, 200–2000mg), oxycodone (N = 33, 100mg, 10–170mg), codeine (N = 20, 600mg, 360–1200mg), and morphine (N = 9, 100mg, 25–200mg). Of patients prescribed hydromorphone, 61 (53.5%) were prescribed > 20mg. Overall, 35 patients (4.3%) had a pain related ED visit <1 month after discharge, of which 14 (40%) received an opioid prescription on initial discharge, and 12 (34.2%) received an opioid prescription upon subsequent discharge. Conclusion: Amongst patients presenting to the ED with acute fractures, the majority were not discharged home with an opioid prescription from ED physicians. Hydromorphone was the most common opioid prescribed, with large variations in total dosage. Despite only a minority of patients receiving opioid prescriptions, there were very few return to ED visits. To limit potential abuse, we recommend standardization of opioid prescribing in the ED, with attention to limiting the total dosage given.

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Recurrent Emergency Department Users: Two Categories with Different Risk Profiles

Journal of Clinical Medicine ◽

10.3390/jcm8030333 ◽

2019 ◽

Vol 8 (3) ◽

pp. 333 ◽

Cited By ~ 4

Author(s):

Ksenija Slankamenac ◽

Meret Zehnder ◽

Tim Langner ◽

Kathrin Krähenmann ◽

Dagmar Keller

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Emergency Services ◽

Hospital Admissions ◽

Tertiary Care ◽

Chronic Obstructive ◽

Care Hospital ◽

Co Morbidity ◽

Ed Visits ◽

Morbidity Index

Recurrent emergency department (ED) visits are responsible for an increasing proportion of overcrowding. Therefore, our aim was to investigate the characteristics and prevalence of recurrent ED visitors as well as to determine risk factors associated with multiple ED visits. ED patients visiting the ED of a tertiary care hospital at least four times consecutively in 2015 were enrolled. Of 33,335 primary ED visits, 1921 ED visits (5.8%) were performed by 372 ED patients who presented in the ED at least four times within the one-year period. Two different categories of recurrent ED patients were identified: repeated ED users presenting always with the same symptoms and frequent ED visitors who were suffering from different symptoms on each ED visit. Repeated ED users had more ED visits (p < 0.001) and needed more hospital admissions (p < 0.010) compared to frequent ED users. Repeated ED users visited the ED more likely due to symptoms from chronic obstructive pulmonary diseases (p < 0.001) and mental disorders (p < 0.001). In contrast, frequent ED patients showed to be at risk for multiple ED visits when being disabled (p = 0.001), had an increased Charlson co-morbidity index (p = 0.004) or suffering from rheumatic diseases (p < 0.001). A small number of recurrent ED visitors determines a relevant number of ED visits with a relevance for and impact on patient centred care and emergency services. There are two categories of recurrent ED users with different risk factors for multiple ED visits: repeated and frequent. Therefore, multi-professional follow-up care models for recurrent ED patients are needed to improve patients’ needs, quality of life as well as emergency services.

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Chronic Pain in the Emergency Department: A Pilot Interdisciplinary Program Demonstrates Improvements in Disability, Psychosocial Function, and Healthcare Utilization

Pain Research and Management ◽

10.1155/2018/1875967 ◽

2018 ◽

Vol 2018 ◽

pp. 1-10 ◽

Cited By ~ 5

Author(s):

Joshua A. Rash ◽

Patricia A. Poulin ◽

Yaadwinder Shergill ◽

Heather Romanow ◽

Jeffrey Freeman ◽

...

Keyword(s):

Emergency Department ◽

Chronic Pain ◽

Pain Catastrophizing ◽

Tertiary Care ◽

Care Plan ◽

Care Hospital ◽

Opioid Use ◽

Care Plans ◽

Individualized Care ◽

Ed Visits

Objective. To evaluate the feasibility of an individualized interdisciplinary chronic pain care plan as an intervention to reduce emergency department (ED) visits and improve clinical outcomes among patients who frequented the ED with concerns related to chronic pain. Methods. A prospective cohort design was used in an urban tertiary care hospital. As a pilot program, fourteen patients with chronic pain who frequented the ED (i.e., >12 ED visits within the last year, of which ≥50% were for chronic pain) received a rapid interdisciplinary assessment and individualized care plan that was uploaded to an electronic medical record system (EMR) accessible to the ED and patient’s primary care provider. Patients were assessed at baseline and every three months over a 12-month period. Primary outcomes were self-reported pain and function assessed using psychometrically valid scales. Results. Nine patients completed 12-month follow-up. Missing data and attrition were handled using multiple imputation. Patients who received the intervention reported clinically significant improvements in pain, function, ED visits, symptoms of depression, pain catastrophizing, sleep, health-related quality of life, and risk of future aberrant opioid use. Discussion. Individualized care plans uploaded to an EMR may be worth implementing in hospital EDs for high frequency visitors with chronic pain.

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Combination pretest probability assessment and D-dimer did not reduce outpatient imaging for venous thromboembolism in a tertiary care hospital emergency department

CJEM ◽

10.2310/8000.2013.130986 ◽

2014 ◽

Vol 16 (01) ◽

pp. 53-62 ◽

Cited By ~ 1

Author(s):

Sarah Ingber ◽

Rita Selby ◽

Jacques Lee ◽

William Geerts ◽

Elena Brnjac

Keyword(s):

Emergency Department ◽

Venous Thromboembolism ◽

False Positive Rate ◽

Tertiary Care ◽

Real Life ◽

Pretest Probability ◽

Care Hospital ◽

Ed Visits ◽

The Impact ◽

D Dimer

ABSTRACTIntroduction:Venous thromboembolism (VTE) is difficult to diagnose yet potentially life threatening. A low-risk pretest probability (PTP) assessment combined with a negative Ddimer can rule out VTE in two-thirds of outpatients, reducing the need for imaging. Real-life implementation of this strategy is associated with several challenges.Methods:We evaluated the impact of introducing a standardized diagnostic algorithm including a mandatory PTP assessment and D-dimer on radiologic test use for VTE in our emergency department (ED). A retrospective review of all ED visits for suspected VTE in the year prior to and following the introduction of this algorithm was conducted. VTE diagnosis was based on imaging. Guideline compliance was also assessed.Results:ED visits were investigated for suspected VTE in the pre- and postintervention periods (n 5 1,785). Most D-dimers (95%) ordered were associated with a PTP assessment, and 50% of visits assigned a low PTP had a negative D-dimer. The proportion of imaging tests ordered for VTE in all ED visits was unchanged postintervention (1.9% v. 2.0%). The proportion of patients with suspected VTE in whom VTE was confirmed on imaging decreased postintervention (10.2% v. 14.1%).Conclusion:In spite of excellent compliance with our algorithm, we were unable to reduce imaging for VTE. This may be due to a lower threshold for suspecting VTE and an increase in investigation for VTE combined with a high false positive rate of our D-dimer assay in low–pretest probability patients. This study highlights two common real-life challenges with adopting this strategy for VTE investigation.

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Epidemiological profile of non-urgent patient visits to emergency department in a tertiary care hospital in South India

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20195841 ◽

2019 ◽

Vol 7 (1) ◽

pp. 128

Author(s):

Arun Anbumani ◽

Moses Kirubairaj Amos Jegaraj ◽

Reka Karruppusami

Keyword(s):

Emergency Department ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Significant Proportion ◽

Admission Rate ◽

Urgent Care ◽

Minor Trauma ◽

Care Hospital ◽

Ed Visits ◽

Epidemiological Profile

Background: Non-urgent visits to emergency department (ED) form a significant proportion of ED visits. The reasons vary from minor injuries, fever of short duration, parental anxiety, and even serious conditions like myocardial infarctions presenting atypically. Non-urgent visits stress the ED services while prolonged waiting affects the patients. The aim was to study the profile of non-urgent visits to emergency department of a tertiary care hospital in South India.Methods: Prospective and descriptive study of patients aged 15 years and above categorized as non-urgent after triage was conducted. Data such as age, gender, reason for visit, time of presentation during the day, duration of ED stay and need for referral were recorded. Quantitative variables were presented as Mean±SD and frequency with percentage for qualitative variables.Results: Non-urgent visits contributed to 47.1% of total ED visits. Reasons for non-urgent visits were fever (15.4%), vomiting (13.9%), breathlessness (7.6%), minor trauma (7.3%), giddiness (7.0%) and dysuria (5.5%). 80.8% of all non- urgent visits were seen by ED doctor within two hours of being triaged. Most patients were treated for their immediate symptoms and 64.8% needed follow-up out-patient appointments. Admission rate was 1.2%. Majority of non-urgent visits (55.7%) were daytime visits and 13% were after-hours.Conclusions: Non-urgent visits contribute to about half of all ED visits and can stress ED. A local triage guideline is necessary to run these services in ED. Extended general practice or family physician run urgent care can relieve the stress on ED while rendering to patients accessible and affordable care.

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The association of chest radiographic findings and severity scoring with clinical outcomes in patients with COVID-19 presenting to the emergency department of a tertiary care hospital in Pakistan

PLoS ONE ◽

10.1371/journal.pone.0244886 ◽

2021 ◽

Vol 16 (1) ◽

pp. e0244886

Author(s):

Raima Kaleemi ◽

Kiran Hilal ◽

Ainan Arshad ◽

Russell Seth Martins ◽

Avinash Nankani ◽

...

Keyword(s):

Emergency Department ◽

Clinical Outcomes ◽

Tertiary Care Hospital ◽

Imaging Modality ◽

Tertiary Care ◽

Multivariable Analysis ◽

Care Hospital ◽

X Rays ◽

Radiographic Findings ◽

Icu Admission

Introduction While chest x-rays (CXRs) represent a cost-effective imaging modality for developing countries like Pakistan, their utility for the prognostication of COVID-19 has been minimally explored. Thus, we describe the frequency and distribution of CXR findings, and their association with clinical outcomes of patients with COVID-19. Methods All adult (≥ 18 years) patients presenting between 28th February-31st May to the emergency department of a tertiary care hospital in Pakistan, who were COVID-19 positive on RT-PCR with CXR done on presentation, were included. A CXR Severity Score (CXR-SS) of 0–8 was used to quantify the extent of pulmonary infection on CXR, with a score of 0 being negative and 1–8 being positive. The patients’ initial CXR-SS and their highest CXR-SS over the hospital course were used for analysis, with cut-offs of 0–4 and 5–8 being used to assess association with clinical outcomes. Results A total of 150 patients, with 76.7% males and mean age 56.1 years, were included in this study. Initial CXR was positive in 80% of patients, and 30.7% of patients had an initial CXR-SS between 5–8. The mortality rate was 16.7% and 30.6% patients underwent ICU admission with intubation (ICU-Int). On multivariable analysis, initial CXR-SS (1.355 [1.136–1.616]) and highest CXR-SS (1.390 [1.143–1.690]) were predictors of ICU-Int, and ICU-Int was independently associated with both initial CXR-SS 5–8 (2.532 [1.109–5.782]) and highest CXR-SS 5–8 (3.386 [1.405–8.159]). Lastly, age (1.060 [1.009–1.113]), initial CXR-SS (1.278 [1.010–1.617]) and ICU-Int (5.047 [1.731–14.710]), were found to be independent predictors of mortality in our patients. Conclusion In a resource-constrained country like Pakistan, CXRs may have valuable prognostic utility in predicting ICU admission and mortality. Additional research with larger patient samples is needed to further explore the association of CXR findings with clinical outcomes.

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P091: Anaphylaxis: epidemiology and treatment in a Canadian emergency department

CJEM ◽

10.1017/cem.2016.267 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S108-S109

Author(s):

J. Morris ◽

A. Marcotte ◽

S. La Vieille ◽

R. Alizadehfar ◽

E. Perkins ◽

...

Keyword(s):

Emergency Department ◽

Chart Review ◽

Treatment Guidelines ◽

Tertiary Care ◽

Care Hospital ◽

H1 Antihistamines ◽

Ed Visits ◽

Anaphylaxis Registry ◽

Current Guidelines ◽

Auto Injector

Introduction: As part of the multicenter C-CARE (Cross-Canada Anaphylaxis Registry) project, this study aimed to describe the characteristics of anaphylactic reactions and assess if emergency physicians follow treatment guidelines. Methods: A cohort study was conducted in the emergency department of Sacré-Cœur Hospital, a university-affiliated, urban tertiary care hospital. For each anaphylaxis case recruited by the treating physician, a standardised questionnaire was completed. The information for missed cases was collected retrospectively through chart review. Results: Between May 2012 and May 2015, 280 cases (205 prospective and 75 retrospective) of anaphylaxis were identified from a total of 182,408 ED visits. The median age was 36.21 years (IQR 27.8), 61.8% were female, and 12.5% of all patients were children (<18 years old). The majority of reactions were triggered by food [54.3% (95%CI:48.5-60.1%)], followed by medications [18.2% (95%CI:13.7-22.7%)] and venom [5.7% (95%CI:3.0-8.4%)]. Among all cases, 66.8% (95%CI:61.3-72.3%) received epinephrine; 26.1% (95%CI:21.0-31.2%) received it prior to their arrival and 46.8% (95%CI:41.0-52.6%) in-hospital. As for other in-hospital treatments, 85.4% of patients (95%CI:81.3-89.5%) received corticosteroids, 81.1% (95%CI:76.5-85.7%) received H1 antihistamines, and 41.1% (95%CI:35.3-46.9%) received H2 antihistamines. Out of all patients who had anaphylaxis, 86.4% (95%CI:82.4-90.4%) were prescribed an epinephrine auto-injector in-hospital or had already had one prescribed. Conclusion: Our results reveal that food is a major trigger of anaphylaxis and that despite current guidelines, there is under use of epinephrine and preferential use of corticosteroids and antihistamines.

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Standing at the edge of mortality; Five-year audit of an emergency department of a tertiary care hospital in a low resource setup

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.37.3.3680 ◽

2021 ◽

Vol 37 (3) ◽

Author(s):

Sama Mukhtar ◽

Syed Ghazanfar Saleem ◽

Saima Ali ◽

Sarfraz Ahmed Khatri ◽

Anna Q Yaffee

Keyword(s):

Emergency Department ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Healthcare Sector ◽

Care Hospital ◽

Delayed Presentation ◽

Do Not Resuscitate ◽

Low Resource ◽

Coronary Syndrome ◽

Ed Visits

Background & Objective: Understanding the demographics of mortality and its burden in the emergency department of a tertiary care setup can lead to better planning and allocation of resources to streamline process flow. This can be achieved systematically through mortality audit that can identify the loopholes and areas of improvement. Our objective was to characterize the epidemiology of ED mortality in a tertiary care hospital of Karachi, Pakistan. Methods: A five-year retrospective chart review of 322 adult mortalities presenting between January l, 2014 – December 31, 2018 was conducted in the emergency department (ED) of The Indus Hospital (TIH), Karachi. All expiries in ED were included while those brought dead and with do not resuscitate order (DNAR) were excluded. Results: Mortality incidence of 0.076% (7.6/10,000 ED visits in five years) was reported. Amongst 507,759 adult ED visits, 322 mortalities were documented. Mean time lapse before presentation was 44±147 hours and mean length of stay before death was 3.4±2.8 hours. Acute coronary syndrome (ACS) was the predominant cause of death with 109 (33.8%) expiries. Significant association was reported between no history of prior care and high priority (P1) cases (p=0.013). Conclusions: This study identified the contributing factors to adverse outcome such as delayed presentation with systemic gaps in management and unknown disposition. The need to improve these factors at local and national level can lead to improvement in Pakistani healthcare sector. doi: https://doi.org/10.12669/pjms.37.3.3680 How to cite this:Mukhtar S, Saleem SG, Ali S, Khatri SA, Yaffee AQ. Standing at the edge of mortality; Five-year audit of an emergency department of a tertiary care hospital in a low resource setup. Pak J Med Sci. 2021;37(3):---------. doi: https://doi.org/10.12669/pjms.37.3.3680 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Effective Utilization of Limited Isolation Rooms to Provide Safe Patient Care and Staff Safety in a Low- and Middle-Income Country

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.746 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s203-s204

Author(s):

Rozina Roshanali

Keyword(s):

Emergency Department ◽

Tertiary Care ◽

Limited Resource ◽

Multidrug Resistant ◽

Communicable Diseases ◽

Care Hospital ◽

Middle Income ◽

Safe Patient Care ◽

Bed Management ◽

Resource Setting

Background: My tertiary-care hospital is a 750-bed hospital with only 17 airborne infection isolation room (AIIR) and negative-pressure rooms to isolate patients who have been diagnosed or are suspected with prevalent diseases like tuberculosis, measles, and chickenpox. On the other hand, only 14 single-patient isolation rooms are available to isolate patients with multidrug-resistant organisms (MDROs) such as CRE (carbapenum-resistant Enterobacter) or colistin-resistant MDROs. Due to the limited number of isolation rooms, the average number of hours to isolate infected patients was ~20 hours, which ultimately directly placed healthcare workers (HCWs) at risk of exposure to infected patients. Methods: Plan-Do-Study-Act (PDSA) quality improvement methodology was utilized to decrease the average number of hours to isolate infected patients and to reduce the exposure of HCWs to communicable diseases. A detailed analysis were performed to identify root causes and their effects at multiple levels. A multidisciplinary team implemented several strategies: coordination with information and technology team to place isolation alerts in the charting system; screening flyers and questions at emergency department triage; close coordination with admission and bed management office; daily morning and evening rounds by infection preventionists in the emergency department; daily morning meeting with microbiology and bed management office to intervene immediately to isolate patients in a timely way; infection preventionist on-call system (24 hours per day, 7 days per week) to provide recommendations for patient placement and cohorting of infected patients wherever possible. Results: In 1 year, a significant reduction was achieved in the number of hours to isolate infected patients, from 20 hours to 4 hours. As a result, HCW exposures to communicable diseases also decreased from 6.7 to 1.5; HCW exposures to TB decreased from 6.0 to 1.9; exposures measles decreased from 4.75 to 1.5; and exposures chickenpox decreased from 7.3 to 1.0. Significant reductions in cost incurred by the organization for the employees who were exposed to these diseases for postexposure prophylaxis also decreased, from ~Rs. 290,000 (~US$3,000) to ~Rs. 59,520 (~US$600). Conclusions: This multidisciplinary approach achieved infection prevention improvements and enhanced patient and HCW safety in a limited-resource setting.Funding: NoneDisclosures: None

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US Emergency Department Visits for Adverse Drug Events From Antibiotics in Children, 2011–2015

Journal of the Pediatric Infectious Diseases Society ◽

10.1093/jpids/piy066 ◽

2018 ◽

Vol 8 (5) ◽

pp. 384-391 ◽

Cited By ~ 8

Author(s):

Maribeth C Lovegrove ◽

Andrew I Geller ◽

Katherine E Fleming-Dutra ◽

Nadine Shehab ◽

Mathew R P Sapiano ◽

...

Keyword(s):

Emergency Department ◽

Adverse Drug Events ◽

Emergency Department Visits ◽

Drug Event ◽

Injury Surveillance System ◽

Adverse Event Data ◽

Systemic Medication ◽

Ed Visits ◽

Pharmacy Dispensing Data

Abstract Background Antibiotics are among the most commonly prescribed medications for children; however, at least one-third of pediatric antibiotic prescriptions are unnecessary. National data on short-term antibiotic-related harms could inform efforts to reduce overprescribing and to supplement interventions that focus on the long-term benefits of reducing antibiotic resistance. Methods Frequencies and rates of emergency department (ED) visits for antibiotic adverse drug events (ADEs) in children were estimated using adverse event data from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project and retail pharmacy dispensing data from QuintilesIMS (2011–2015). Results On the basis of 6542 surveillance cases, an estimated 69464 ED visits (95% confidence interval, 53488–85441) were made annually for antibiotic ADEs among children aged ≤19 years from 2011 to 2015, which accounts for 46.2% of ED visits for ADEs that results from systemic medication. Two-fifths (40.7%) of ED visits for antibiotic ADEs involved a child aged ≤2 years, and 86.1% involved an allergic reaction. Amoxicillin was the most commonly implicated antibiotic among children aged ≤9 years. When we accounted for dispensed prescriptions, the rates of ED visits for antibiotic ADEs declined with increasing age for all antibiotics except sulfamethoxazole-trimethoprim. Amoxicillin had the highest rate of ED visits for antibiotic ADEs among children aged ≤2 years, whereas sulfamethoxazole-trimethoprim resulted in the highest rate among children aged 10 to 19 years (29.9 and 24.2 ED visits per 10000 dispensed prescriptions, respectively). Conclusions Antibiotic ADEs lead to many ED visits, particularly among young children. Communicating the risks of antibiotic ADEs could help reduce unnecessary prescribing. Prevention efforts could target pediatric patients who are at the greatest risk of harm.

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