The Joint Commission Update for Infection Control: Joint commission warns of pediatric med errors
The Joint Commission Update for Infection Control
Joint commission warns of pediatric med errors
Issues sentinel alert on key patient safety issue
The Joint Commission continues to emphasize the patient safety issue of medication administration, warning that children are at particular risk of harmful medication errors. In a Sentinel Event Alert issued April 11, 2008, The Joint Commission emphasized that errors associated with medications are among the most common type of medical error and are a significant cause of preventable adverse events. Moreover, it is clear that those medication errors have the potential to cause harm within the pediatric population at a higher rate than in the adult population. For example, medication dosing errors are more common in pediatrics than adults because of weight-based dosing calculations, fractional dosing (e.g., mg vs. gm), and the need for decimal points.
"Research shows that the potential for adverse drug events within the pediatric inpatient population is about three times as high as among hospitalized adults," says Stu Levine, PharmD, informatics and pediatric specialist, Institute for Safe Medication Practices, an organization that serves as a resource for information on how to improve medication practices. "For this reason, health care providers must pay special attention to the specific challenges relating to the pediatric population."
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, the Joint Commission emphasized. This is 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
Children are more prone to medication errors and resulting harm because most meds used in the care of children are formulated and packaged primarily for adults. Therefore, medications often must be prepared in different volumes or concentrations within the health care setting before being administered to children. The need to alter the original medication dosage requires a series of pediatric-specific calculations and tasks, each significantly increasing the possibility of error. In addition, most health care settings are primarily built around the needs of adults. Many settings lack trained staff oriented to pediatric care, pediatric care protocols and safeguards, and/or up-to-date and easily accessible pediatric reference materials, especially with regard to medications. Emergency departments may be particularly risk-prone environments for children. To make matters worse, children — especially young, small, and sick ones — usually are less able to physiologically tolerate a medication error due to still-developing renal, immune, and hepatic functions. Many children, especially very young ones, cannot communicate effectively to providers regarding any adverse effects that medications may cause.
Pediatric-specific strategies for reducing medication errors include:
- Establishing and maintaining a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use;
- standardizing how days are counted in all protocols by deciding upon a protocol start date (e.g., Day 0 or Day 1) in order to prevent timing errors in medication administration;
- limiting the number of concentrations and dose strengths of high-alert medications to the minimum needed to provide safe care;
- ensuring 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) for pediatric patients who are receiving compounded oral medications and total parenteral nutrition at home;
- using 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.
(Editors' note: The Sentinel Event Alert is available at: http://www.jointcommission.org.)
- 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:e927-e935. Available online: http://www.pediatrics.org (accessed 4/8/08).
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