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Put a stop to errors with weight-based dosage
Young children are at greater risk for dosage mistakes, as they often receive medications available in multiple formulations and concentrations, warns Jennifer McNamara, RN, an ED nurse at Children's Hospital Boston.
"Also, children are more sensitive to dosing errors," McNamara adds.
Stacey Peki, RN, an ED nurse at Baptist Children's Hospital in Miami, says that when the ED physician writes an order for the medication based on the child's weight, "there could potentially be errors anywhere in this process, and the patient could receive the wrong dose of medication."
To avoid weight-based dosage errors, consider these clinical practices:
Use intravenous (IV) infusion devices with smart pumps.
"When a nurse provides the patient's weight to the smart pump, the calculations are provided automatically, reducing the risk of human error in this step," says Andrew D. Harding, RN, CEN, an ED clinical nurse specialist at Caritas Good Samaritan Medical Center, Brockton, MA.
"Hard limits," the pre-programmed volume of medication which is out of any recommended therapeutic range, can prevent catastrophic harm through intravenous (IV) infusion. "When the smart pump reaches the hard limit, it prevents the infusion from occurring," says Harding.
At Providence St. Vincent Medical Center in Portland, OR, standardized pediatric infusion pumps are pre-programmed with patient weight groups and frequently administered medications, says Renee M. Rich, RN, BSN, an ED nurse. "This allows for an additional system of double checking medications prior to IV infusions," says Rich.
Use order sheets.
"Almost all medications for pediatric patients must be calculated," Rich says. "ED nurses and pharmacists must dilute stock medications or divide pills."
To prevent dosage errors, ED nurses use standardized medication order sheets. These list the patient's weight in kilograms, old and new allergies, and drug reactions. These order sheets also include the medication name and unit of measurement per kilogram, such as units/kg, mg/kg, and mcg/kg, and the total dose of the medication.
"This system allows for a double check on all ordered medications," Rich says. "Ordering physicians are encouraged write out all instructions and to avoid using abbreviations."
Avoid use of terminal zero.
"Use '5' instead of '5.0' to avoid 10-fold dosing errors," says Rich. "Use a zero to the left of a dose less than 1." Instead of ".1," "0.1" is what you should document.
Use a template to calculate drugs used during a code.
"Medication administration during a code situation can provide an environment that is prone to medication errors," says Rich.
To prevent these errors, ED nurses use a template that calculates code medications and drip medications. "These code medication sheets are individualized to each patient," says Rich.
Chart weight before pound conversion
ED nurses at Seattle Children's Hospital have caught a few dose-calculated weight errors and have performed a root cause analysis on every single one, says Elaine Beardsley, MN, RN, CPEN, ED clinical nurse specialist.
"Most were identified before the child received any medications or IV [intravenous] fluid," Beardsley adds.
ED nurses determined that most of the mistakes occurred because the scale wasn't directly beside the computer, so nurses had to walk across the triage room to enter the weight.
During that time, the parent often asked the ED nurse to tell them the child's weight in pounds. The nurse then would calculate the weight in pounds, then enter the weight in kilograms on the chart. "Either the pound weight was entered, or the numbers got mixed up, because numbers are difficult to remember," says Beardsley.
To avoid this, ED nurses don't do a kilogram-pound conversion until the weight is documented. "Tell the parent that you will answer question after weight is entered to ensure safety and accuracy," says Beardsley. "Never do mental math."
She gives these other solutions for this common problem: