Joint Commission warns of pediatric medication errors, urges action
Most errors involve improper dose or quantity
The Joint Commission is ringing the alarm bell on pediatric medication errors, saying the health care community has not responded aggressively enough to the increased risk children face when a health care provider administers drugs to them. The chance of medication error is significantly higher with young patients, and the Commission says providers must take deliberate steps to protect them.
This is the first time the group has singled out the problem so specifically, and it is offering many strategies risk managers can use to reduce the risk. The risk of medication errors with children is three times higher than it is for an adult, The Joint Commission notes. Part of the problem, the group says, is that most hospitals' policies and procedures are not designed with children in mind. Most medications also are formulated and packaged for adults, which means that staff must make adjustments for children, and each manual alteration of the dosage increases the potential for errors.
Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission, says risk managers must take action. "We can and we're obligated to do better," he says.
Matthew Scanlon, MD, assistant professor of pediatrics-critical care at the Medical College of Wisconsin in Milwaukee and a member of The Joint Commission's Sentinel Event Advisory Group, says the risk of pediatric medication errors has been neglected, even as the health care community focused more on patient safety in recent years.
"Sadly, there seems to be a lack of widespread appreciation even among health care providers that children have unique safety and medication needs," he says. "The issues of having to adapt products, be it technology or medications, that were created for adults and apply those to pediatric patients is terribly problematic and really is the source of a great deal of work that has to be performed on a daily basis among pediatric health care providers."
Pediatric medication errors have received increased attention in recent months, most notably with an incident that threatened the lives of actor Dennis Quaid's young twins. Quaid's twins Thomas Boone and Zoe Grace nearly died in November 2007 at Cedars-Sinai Hospital in Los Angeles when they were mistakenly given a heparin overdose. The Quaid twins were mistakenly given the drug, an adult-strength blood thinner, instead of Hep-Lock, a version of the drug a thousand times weaker that is routinely used to clear IV lines in pediatric patients.
Weighing children is first step
One of the most important ways to reduce pediatric medication errors actually is one of the simplest, Angood says. Because staff must calculate the correct dosage for pediatric patients rather than using the standardized doses intended for adult patients, and because even small calculation errors can have a major impact with small patients, knowing the child's weight is critical, he says. That is why The Joint Commission is recommending that all pediatric patients be weighed on admission every time. And in kilograms, not pounds.
"The vast majority of countries utilize the metric system, and the recommendations for pediatric medication use are based on the metric system," Angood says. 'This should become the standard of recording pediatric patient weights."
The Joint Commission's April 11, 2008, Sentinel Event Alert addresses pediatric medication errors, and urges greater attention to precautions such as medication standardization, improved medication identification and communication techniques, as well as the use of kilograms as the standard weight measurement to calculate proper dosages.1
Most of the harmful pediatric medication errors tracked during the past two years by U.S. Pharma-copeia involved either an improper dose or quantity, according to the Alert. Problems typically arise when hospitals and clinics are forced to prepare special volumes or concentrations, because the drugs are formulated and packaged primarily for adults. The need to alter the original medication dosage requires a series of calculations and tasks that increase the chance for error.
Another problem is that younger patients cannot participate in their health care the same way adults can, says Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission.
"Children often lack the communication skills to tell caregivers if something is wrong, which increases the responsibility of caregivers to carefully monitor their care to keep them safe," he says. "Organizations and caregivers must commit themselves to using effective risk reduction strategies to make a difference in preventing pediatric medication errors."
Medication dosing errors also are more common in pediatrics than adults because of fractional dosing and the need for decimal points, says Stu Levine, PharmD, an informatics and pediatric specialist with the Institute for Safe Medication Practices in Horsham, PA, an organization which serves as a resource for information on how to improve medication practices. In the Alert, Levine notes that research shows that the potential for adverse drug events within the pediatric inpatient population is about three times as high as among hospitalized adults.
The Alert also encourages organizations: to be open and transparent if an error occurs in order to facilitate learning so that future errors can be prevented; drug manufacturers to develop pediatric-specific formulations and to standardize labeling and packaging of all medications; and parents to seek out information and ask questions about their child's medications and to repeat back instructions to health care professionals in order to avoid mix-ups.
Risk reduction can work
The risk reduction strategies suggested by The Joint Commission can have a major impact, says Sara White, MS, FASHP, a pharmacy leadership coach in Boston who previously was director of pharmacy and clinical professor for Stanford Hospital and Clinics in Palo Alto, CA, and was faced with the responsibility of managing patient safety. She says a strong partnership with the risk management department at Stanford Hospital and Clinics was essential to reducing pediatric medication errors.
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Latest research shows error risk with kids A new study, the first to develop and evaluate a trigger tool to detect adverse drug events in an inpatient pediatric population, identified an 11.1% rate of adverse drug events in pediatric patients, far more than described in previous studies. The study also showed that 22% of those adverse drug events were preventable, 17.8% could have been identified earlier, and 16.8% could have been mitigated more effectively.1 During calendar years 2006-2007, the MEDMARX database from the U.S. Pharmacopeia in Rockville, MD, shows nearly 2.5% of pediatric medication errors led to patient harm. The most common types of harmful pediatric medication errors were: improper dose/quantity (37.5%), omission error (19.9%), unauthorized/wrong drug (13.7%), and prescribing error (9.4%), followed by wrong administration technique, wrong time, drug prepared incorrectly, wrong dosage form, and wrong route. Medication errors involving pediatric patients were most often caused by: performance deficit (43%), knowledge deficit (29.9%), procedure/protocol not followed (20.7%), and miscommunication (16.8%), followed by calculation error, computer entry error, inadequate or lack of monitoring, improper use of pumps, and documentation errors. The MEDMARX Data Report reveals that approximately 32.4% of pediatric errors in the operating room involve an improper dose/quantity compared with 14.6% in the adult population and 15.4% in the geriatric population. Reference 1. Takata, GS, et al. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in U.S. children's hospitals. Pediatrics 2008; 121(4):e927-35. |
"The first thing a risk manager should do is meet with the director of pharmacy and offer to help. I'm certain that offer will be well received," she says. "Ask what the pharmacy needs help with, and pull from your different resources."
Risk managers should make sure they are on the distribution list for any publications or alerts regarding medication errors, White suggests. The Institute for Safe Medication Practices (ISMP) in Horsham, PA, is a valuable resource, and White urges risk managers to visit the group's web site at www.ISMP.org to access tools and information that can be used to reduce errors.
"We had ISMP come in and do an assessment for us. They looked at us with outside eyes and gave us recommendations for how we could tighten our system up," she says. "Even though you think you have a tight system, somebody from the outside can find ways to improve. It costs a little bit of money, but so does a lawsuit."
The risk manager also can be involved in obtaining the automated systems that can reduce many medication errors, White says. Remember that getting the automated dispensing system or similar electronic safeguards in place only is the first step. You have to keep the technology current, she adds.
"The pharmacy director can make the case for why you need it, but the risk manager can help with some of the politics in the organization getting things approved and funded," she says. "The risk manager also can be great help in getting the message to caregivers about how and why procedures have to change. It makes a big difference when, after I make the case to a caregiver, another person from the organization comes along and reinforces that message."
Automation is key step
Automated systems are often cited as the way to reduce human error in medication administration, and Bill Churchill, MS, RPh, executive director of pharmacy services at Boston's Brigham and Women's Hospital, says that is the case at his hospital. For the past six years, the hospital has been on a quest to eliminate medication errors, and a key part of that effort has been increasing patient safety and hospital staff efficiency through the use of automated medication management systems.
Churchill says the first step in reducing medication errors is to understand what systems you have in place now, and what type of errors are occurring. Risk managers can contribute to that analysis and data collection, he says.
"Everyone needs to understand where the weaknesses are before you go forward," he says. "The worst thing you can do is automate a bad system."
Brigham and Women's uses a number of high-tech methods to reduce the risk of errors, including bar code technology used throughout the pharmacy and at all points in the dispensing process, including at the bed side. The hospital has pharmacy professionals on the units who can communicate with the central pharmacy wireless connections, and the automated dispensing systems are all interfaced with the electronic medication records system and the automated infusion pumps. The interconnectedness is all designed to eliminate errors that happen when one person or one system doesn't know what the other has done with a patient's medication, he says.
"That kind of multifaceted approach requires a team approach," he says. "You need pharmacy, physicians, nursing, and risk management to drive this through. Risk management can play a huge role by being a champion for the effort, someone to carry this forward and to constantly make the case for this change with senior management."
Reference
1. The Joint Commission. Preventing pediatric medication errors. Sentinel Event Alert 2008; Issue 39, April 11, 2008.
Sources
For more information on reducing pediatric medication errors, contact:
- Peter Angood, MD, Vice President and Chief Patient Safety Officer, The Joint Commission, Oakbrook Terrace, IL. Telephone: (630) 792-5000.
- Bill Churchill, MS, RPh, Executive Director, Pharmacy Services, Brigham and Women's Hospital, Boston. Telephone: (617) 732-7164. E-mail: [email protected].
- Stu Levine, PharmD, Informatics and pediatric Specialist, Institute for Safe Medication Practices, Horsham, PA. Telephone: (215) 947-7797.
- Matthew Scanlon, MD, Assistant Professor, Pediatrics-Critical Care, Medical College of Wisconsin, Milwaukee. Telephone: (414) 266-2000.
- Sara White, MS, FASHP, Pharmacy Leadership Coach, Boston. Telephone: (650) 988-8987. E-mail: [email protected].
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