Training, standardized procedures are key
The Joint Commission's April 11, 2008, Sentinel Event Alert offers a number of risk reduction strategies for pediatric medication errors.1 Here are some highlights of The Joint Commission's advice:
- Standardize and identify medications effectively, as well as the processes for drug administration.
- Establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use.
- To prevent timing errors in medication administration, standardize how days are counted in all protocols by deciding upon a protocol start date, such as Day 0 or Day 1.
- Limit the number of concentrations and dose strengths of high-alert medications to the minimum needed to provide safe care.
- For pediatric patients who are receiving compounded oral medications and total parenteral nutrition at home, ensure that the doses are equivalent to those prepared in the hospital (i.e., the volume of the home dose should be the same as the volume of the hospital-prepared products).
- Use oral syringes to administer oral medications. The pharmacy should use oral syringes when preparing oral liquid medications. Make oral syringes available on patient care units when "as-needed" medications are prepared. Educate staff about the benefits of oral syringes in preventing inadvertent intravenous administration of oral medications.
- Use The Joint Commission's National Patient Safety Goals and Medication Management Stan-dards to guide safe medication practices for pediatric patients.
- Require prescribers to write out how they arrived at the proper dosage, as dose per weight, so that the calculation can be double-checked by a pharmacist, nurse, or both.
- Use pediatric-specific medication formulations and concentrations when possible.
- Clearly differentiate from adult formulations all products that have been repackaged for use in pediatric populations. Use clear, highly visible warning labels. To prevent overdoses, keep concentrated adult medications away from pediatric care units. Avoid storing adult and pediatric concentrations in the same automated dispensing machine/cabinet drawer.
- Ensure comprehensive specialty training for all practitioners involved in the care of infants and children, as well as continuing education programs on pediatric medications for all health care providers. Training and education should include information on how adverse effects should be reported.
- Communicate verbally and in writing information about the child's medication to the child, caregivers and parents/guardians, including information about potential side effects. Ask the caregiver/parent/guardian to repeat back their understanding of the drug and how it is to be administered. Encourage the asking of questions about medications.
- Have a pharmacist with pediatric expertise available or on-call at all times.
- Establish and implement medication procedures that include pediatric prescribing and administration practices.
References
1. The Joint Commission. Preventing pediatric medication errors. Sentinel Event Alert 2008; Issue 39, April 11, 2008.
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