Critically ill kids most likely to suffer from drug errors
The most seriously ill children are more likely than other youngsters in the hospital to experience drug mistakes, according to new research released at the same time as new guidelines on how to avoid such errors with children.
Very sick children also more likely to be involved in "near misses" with medication administration, the research says in a recent article in the Archives of Pediatric and Adolescent Medicine (2003; 157:60-65). The research suggests that the errors may occur because ill children receive more medications, and are not the reason why the children are the sickest in the hospital, as some studies have suggested.
Contrary to some previous reports, researchers led by Mark T. Holdsworth, MD, from the University of New Mexico in Albuquerque, concluded that adverse events related to medications are not the reason seriously ill children are so sick. Previous studies suggesting that medication errors kept children in the hospital were designed poorly, the researchers said.
Why the risk increases
After analyzing data from 992 children admitted to a large metropolitan hospital one or more times between Sept. 15, 2000, and May 10, 2001, the researchers found that adverse drug events occurred in 6% of hospital admissions and potential adverse drug events occurred in 8% of admissions. Seventy-six adverse drug events that occurred, and 18 were considered to be serious or life-threatening. Four of the cases resulted in major or permanent disability.
The risk of adverse drug events increased as the child’s disease severity and medication exposure increased. To reduce the likelihood of drug errors in young patients, the United States Pharmacopeia (USP) recently offered a set of recommendations. USP’s Center for the Advancement of Patient Safety (CAPS) created the recommendations after analyzing medication error data from its databases.
Pediatric care vs. adult care
Many of the errors relate to specifics of pediatric care vs. adult patient care, says Diane Cousins, RPh, vice president of CAPS at USP. Pediatric medication errors often can occur, for example, when a decimal point is misplaced in a medication dose or an incorrect weight conversion from pounds to kilograms is made. Health care practitioners must consider a child’s age, weight, medication dosing frequencies, and a number of other factors to help ensure the safety of young patients.
In December 2002, USP released an analysis of medication errors captured in 2001 by MEDMARX, the anonymous national reporting database operated by USP. Of the 105,603 errors documented by MEDMARX, 3,361 errors, or 3.2% of total errors, involved pediatric populations (birth to 16 years). Although the vast majority of errors were corrected before causing harm to the patient, 190 errors, or 5.7% of total errors, resulted in patient injury. Of this number, 156 resulted in temporary harm to the patient and required intervention, 31 required initial or prolonged hospitalizations, one required intervention to sustain life, and two errors resulted in a patient’s death.
"The risk to the patient can be minimized when using technology to help calculate a dose," Cousins says. "In fact, human factors engineering approaches suggest that accurate, repeated calculations involving multiple steps are better performed using computer-based algorithms. Pre-printed and pre-calculated dosing guidelines can and should be readily available for staff use and verification."
Here are the USP’s recommendations:
- Dosage forms and/or preparations that are compounded, prepared in serial dilutions, and/ or extensively manipulated should be prepared in the pharmacy and verified by a pharmacist. Where possible, a second health care professional familiar with dilutions and compounding should verify the product preparation and labeling.
- Policies and procedures should be developed and implemented when automated dispensing machines are being used for pediatric medications, including double independent verification of medications loaded into the machines and the inability to override system safeguards.
- When possible, medications should be prepared and dispensed as "unit-dose" containers for all pediatric medications in all health care facilities.
- Liquid medications dispensed in the outpatient setting should be dispensed with appropriate measuring devices and instructions for use. When possible, use of the measuring device should be demonstrated to the patient/caregiver.
- The prescription order should be reviewed by a health care professional for appropriateness and dosage accuracy using the patient’s weight, age, and other appropriate dose indicator(s) before dispensing and administering each dose and/or refill for pediatric patients.
- The patient’s weight, age, and other appropriate dose indicator(s) should be available and clearly identified on all prescriptions and orders before the dose is dispensed and administered.
- Wherever possible, pediatric dosages should be calculated by a validated computer algorithm as part of an integrated medication order-entry system. Calculations, whether computerized or manual, should be independently double-checked by a pharmacist and signed off by at least one other licensed health care professional to confirm accuracy.
- Abbreviations, acronyms, and symbols used throughout an organization should be standardized and readily available. A list of abbreviations, acronyms, and symbols that should not be used should also be available.
- To prevent tenfold overdoses, a terminal or trailing zero should never be used after a decimal. A leading zero should always precede a decimal expression of less than one.
- In all health care settings, patients, parents, and/or caregivers should be provided verbal and written information about the pediatric patient’s medication, the common side effects, and the adverse events that should be reported to a health care professional.
The most seriously ill children are more likely than other youngsters in the hospital to experience drug mistakes, according to new research released at the same time as new guidelines on how to avoid such errors with children.
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