Pediatric Medication Error Prevention Debbie Sandlin, RN, CPAN THE ACCIDENTAL blood thinner overdose of actor Dennis Quaid’s twins last November has brought public attention to the issue of pediatric medication errors. According to Stu Levine, PharmD, of the Institute for Safe Medication Practices, ‘‘Research shows that the potential for adverse drug effects within the pediatric inpatient population is about three times as high as among hospitalized adults. For this reason, health care providers must pay special attention to the specific challenges relating to the pediatric population.’’ The Joint Commission published a sentinel event alert in regard to preventing pediatric medication errors. This Resource Center column addresses the issues presented by The Joint Commission.1 The MEDMARX data report of 2006–2007 reveals that approximately 32.4% of pediatric errors that occurred in the OR were the result of improper dose or quantity compared with 14.6% in the adult population and 15.4% of geriatric patients. Errors associated with pediatric medications are a significant cause of preventable adverse events in the health care arena.
Factors Affecting Pediatric Medication Errors The Joint Commission tells us that children are more prone to medication errors and resulting harm largely as a result of the following:
Most health care facilities are built around the needs of adults and lack staff trained specifically for pediatric care, pediatric care protocols, and pediatric safeguards. They may not have up-to-date and easily accessible pediatric reference materials. d Young, small, sick children are usually less able to physiologically tolerate a medication error because of still-developing renal, immune, and hepatic function. d Most young children are unable to communicate effectively to providers regarding adverse effects that medications may be causing. They simply do not know what is wrong or how to tell us, just that they do not feel well. d
Error Reduction According to The Joint Commission, pediatricspecific strategies for medication error reduction should include: Establish a pediatric formulary system Standardize the way days are counted (eg, Day 0 or Day 1) and delineate a protocol start date d Limit the number of concentrations of high-alert medications d For pediatric patients receiving compound oral medications, the volume of the home dose should be the same as the volume of the hospital-prepared product d d
Most medication administered to children is formulated and packaged primarily for adult use and requires pediatric-specific calculations that increase the possibility of error.
Debbie Sandlin, RN, CPAN, is Manager of Outpatient Surgical Services, Southern Hills Medical Center, Nashville, TN. Address correspondence to Debbie Sandlin; e-mail address: [email protected]
Ó 2008 by American Society of PeriAnesthesia Nurses. 1089-9472/08/2304-0011$34.00/0 doi:10.1016/j.jopan.2008.05.007
Journal of PeriAnesthesia Nursing, Vol 23, No 4 (August), 2008: pp 279-281
Use oral syringes to administer all oral medications
Pharmacy Strategies The pharmacy department should be an integral part of the team when dealing with pediatric issues. A practitioner trained in pediatrics should sit on any committee that oversees medication management and should help develop preprinted medication order forms and clinical pathways or protocols to promote a standardized approach to care. Monitoring parameters and reminders should be included in the protocols. A dosage calculation sheet should be provided for each pediatric care patient that includes commonly used medicines as well as emergency medications. All hospital staff should have Internet access for specific pediatric information including research data, growth charts, normal pediatric vital sign parameters, and emergency dosage calculation. The emergency dosing data should include information regarding minimal effective dosing and maximum dosing limits. Pediatric medications should be stored and prepared in a separate area from adult medications. Assigned pharmacists and technicians with pediatric expertise should be available for neonatal/pediatric critical care units and pediatric oncology units.
Technological Safety It is important to realize that the use of smart pump infusion devices does not guarantee that a medication error will not occur. Methods should be established to ensure accuracy of these machines. If available, dose and range–checking software programs should be used to provide alerts for incorrect doses. Automated dispensing machines that do not undergo appropriate pharmacist review should be limited to emergency medicines
that will be given under the control of a licensed independent prescriber. Institutions are encouraged to use bar-coding technology with pediatric capability. The system must be able to provide readable code for small volume, patient-specific dose labeling. Pediatric oversedation during procedures should be prevented by using consistent physiological monitoring, including pulse oximetry. This applies to inpatient hospitals, outpatient surgery centers, clinics, and physicians’ offices. Age- and size-appropriate monitoring equipment should be used, and uniform procedures should be followed. Monitoring should be done by staff, with appropriate training in sedation, monitoring, and resuscitation.
The Joint Commission Recommendations The following are actions suggested by The Joint Commission to prevent pediatric medication errors: d
All pediatric patients should be weighed in kilograms at the time of admission, including outpatient clinics and ambulatory surgery centers. Kilograms should be the standard weight used on all prescriptions, medical records, and staff communications. Pediatric patients should receive no high-risk medication until they have been weighed, unless it is an emergency. Medication policies and procedures should be developed and implemented that include pediatric prescribing and administration. A pharmacist with pediatric expertise must be available or on-call at all times. On both inpatient medication orders and outpatient prescriptions, prescribers are required to include the calculated dose as well as the dosing determination such as dose per weight (ie, milligrams per kilogram). Both the pharmacist and nurse should double-check this
PEDIATRIC MEDICATION ERROR PREVENTION
calculation. (Examples of exceptions to this rule include vitamins, opthalmics, and topical medications.) If available, commercially prepared pediatric-specific formulations and concentrations should be used. When not possible, the pharmacy should dispense all pediatric medications in unit-dose, patient-specific containers. All oral medications should be dispensed and administered in oral syringes to ensure accuracy. Adult and pediatric concentrations should be stored in separate drawers of an automatic dispensing machine. Adult concentrated medications should be kept away from pediatric care units. Use clear, highly visible warning labels on all medications that are adult concentrations which have been converted to a pediatric dose by the pharmacist. All practitioners involved in the care of infants and children should have comprehensive pediatric specialty training, including proper reporting of adverse reactions or side effects. Information about pediatric medication, including information about side effects, should be communicated verbally and in writing to the child (if old enough to understand), to caregivers, and to parents/guardians. The caregiver/parent/ guardian should be asked to repeat the information back to you and demonstrate understanding. Questions should be encouraged and answered.
Error Follow-Up All medication errors should be reported. The facility should conduct a root cause analysis of any serious error or adverse event regarding pediatric medicine. A correction plan must be developed, implemented, and later monitored for effectiveness. The Joint Commission encourages apology and transparency about errors, with both the staff and families involved. The Joint Commission is encouraging pharmaceutical manufacturers to develop pediatricspecific formulas and to standardize packaging and labeling. Researchers are also encouraged to develop interventions to reduce pediatric medication errors, especially in home environments, emergency departments, and ambulatory clinics or surgery centers.
Conclusion In conclusion, pediatric medication errors can be disastrous, are potentially lethal, and, most importantly, may be prevented. By following the advice listed here from The Joint Commission, we can do our part to prevent pediatric medication errors. Medical caregivers should actively involve parents/caregivers in all aspects of the pediatric medical plan. Those parents/caregivers should be encouraged to repeat instructions back to demonstrate a clear understanding, and they should be encouraged to ask questions. Everyone involved must strive to see that pediatric medications are administered safely.
Reference 1. The Joint Commission. Sentinel Event Alert. Preventing pediatric medication errors. Issue 39. Available at: http://
www.jointcommission.org/SentinelEvents/SentinelEventAlert/ sea_39.htm. Accessed on April 11, 2008.