Are pediatric drug errors occurring in your ED? Act now before tragedy strikes
Are pediatric drug errors occurring in your ED? Act now before tragedy strikes
Research reveals high rate of medication mistakes in the ED
While caring for a 3-year-old boy who had been hit by a car, an ED physician mistakenly ordered the adult dose of a defasciculating agent, which was a full paralytic dose for the injured child. The nurse drew up the dose and gave it, calling out "1 mg vecuronium."
"Another physician in the area heard the call out and realized that it was a 10 times overdose for this child," says Robert L. Wears, MD, MS, FACEP, professor of emergency medicine for the College of Medicine at the University of Florida and director of the Center for Safety in Emergency Care, both in Jacksonville, FL.
The doctor informed the team that the patient had just received not a defasciculating dose, but a full paralytic dose and needed prompt intubation, Wears recalls.
The call-out procedure allowed the team to intubate the child quickly rather than be caught by surprise when he stopped breathing, Wears explains. The child was intubated without complications and recovered fully, he reports. The strategies you use can determine whether an incident is a near miss or a tragedy, Wears says.
If you fail to implement effective systems to prevent pediatric medication errors, there can be liability risks for you and your facility, warns Emory Petrack, MD, MPH, MS, chief of the division of pediatric emergency medicine at Rainbow Babies and Childrens Hospital in Cleveland. "In addition, it is very demoralizing for staff when a major adverse outcome occurs that could have been prevented," he says.
Dramatic findings from recent research point to disturbingly high pediatric drug errors in the ED. One study looked at pediatric drug orders in an Albany, NY, ED over a four-year period and found 176 prescribing errors. Many of the errors involved miscalculated doses based on a child’s weight. About a third of the errors could have caused serious adverse outcomes, and 6% were potentially life-threatening.1
Children are at higher risk for drug errors in the ED for many reasons, including a lack of pediatric-trained personnel, prescriptions that aren’t reviewed by a pharmacist, and an overall hectic environment, says Paula Mialon, PharmD, ED pharmacist at Children’s Medical Center in Dallas. "Sometimes, prescriptions are written with the theory that children are just small adults,’" she says.
Here are strategies to reduce pediatric medication errors:
• Address weight-based dosing errors. "One dose does not fit all" for children, Petrack emphasizes. "While some medications have a wide margin of safety for per-kilogram dosing, many others require careful attention to appropriate dosing based on weight," he says. "Generally, the younger the patient, the more concerning this becomes." For critical cases, you may have to "guesstimate" the child’s age and/or weight, Wears says. "People are, in general, pretty bad at this, although they think they’re pretty good," he adds.
To obtain the correct dose, you have to multiply the child’s weight by the dose and do that correctly, Wears notes. "There is a baseline error rate in simple arithmetic of about 3% when done under good conditions, and you’re allowed to check your work," he says. "Now think about doing it at the end of a 12-hour night shift in the ED, in your head, when you’re managing a critically ill child and you’ve been interrupted twice by phone calls or pages."
Sometimes, you have to carry out an additional calculation to get the correct dilution, Wears says. "In all these calculations, a misplaced decimal point is a risk of a tenfold over- or underdose," he says.
The goal should be to eliminate the use of math, Wears says. He recommends using tools that allow you to stop relying on memory and calculation, such as pre-packaged "standard orders" for weight ranges.
Use programs available for PDAs, such as PEPID (Portable Emergency and Primary Care Information Database) manufactured by Chicago-based PEPID, which quickly calculates dosages based on a child’s weight or age, Petrack advises. "Automation of the dosing process can help reduce error," he says.
• Get staff accustomed to looking for "pediatric" dosages. When treating children, you’ll need to obtain uncommonly used drug dosages, such as milligrams/ kilogram, or micrograms/kilogram, instead of standard doses such as 0.25 mg of digoxin or 1.0 g of ceftriaxone, Wears notes. He points to the possibility of confusing milligrams and micrograms and other sound-alike units. "That’s a 1,000-fold difference, so the potential for a disaster is obvious," he says.
This also can occur with adults, but with children, there are fewer red flags to signal that the dose is wrong, Wears says. He gives the example of someone ordering a tenfold overdose of epinephrine in an adult patient. "By the time the nurse opened the second or third vial, someone might have suspected something was wrong," he says. "But a tenfold overdose of epinephrine in a child would not be so immediately obvious."
Since many EDs rarely treat critically ill children, it is easy for a commonly used adult dose to be inadvertently ordered and not recognized as unusual, he explains. To address this problem, you should reduce the numbers of different drugs used and also keep the number of different concentrations and formulations to a minimum, Wears says.
"We should also stop changing suppliers every time we think we can save a few pennies, so drug containers stop changing their appearance constantly," he points out.
• Involve a pharmacist. When an 11 kg child was undergoing conscious sedation, a resident wrote an order for 110 mg of ketamine, a general anesthetic, which was a tenfold overdose.
In another incident, an order was written for the antibiotic gentamicin based on weight, for a child weighing 100 kg. The dose is 2.5 mg/kg, but the resident didn’t realize that there is a maximum dose, which ranges from 80-120 mg for an adult, Mialon explains. "Gentamicin in large doses can cause renal failure and ototoxicity," she adds.
Both these errors were caught by Mialon before the drugs were administered.
Dosages that are compounded, prepared in serial dilutions, or extensively manipulated should be verified by a pharmacist, says the Rockville, MD-based U.S. Pharmacopeia’s Center for the Advancement of Patient Safety in its recommendations for preventing drug errors in children.
Mialon carries a portable phone so she can act as a reference before an order is written for any ED patient. "The residents just call to ask what the correct dose is, so they write it correctly the first time," she says. "The nursing staff love it."
• Find out which drugs are causing errors. Identify the drugs that are most risky for dangerous errors in your ED, such as sedating agents, Petrack advises. "Ideally, dosing for these drugs should be verified by two physicians or nurses," he says.
Reference
1. Rasmus RE, Mitchell AL, Lesar TS. Medication prescribing errors in pediatric emergency medicine: Albany (NY) Medical Center. Abstract presented at American Academy of Pediatrics National Conference, Boston; October 2002.
Sources
For more information on pediatric drug errors, contact:
• Paula Mialon, PharmD, Children’s Medical Center, Department of Pharmacy Services, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-2279. Fax: (214) 456-6014. E-mail: [email protected].
• Emory Petrack, MD, MPH, MS, Chief, Division of Pediatric Emergency Medicine, Rainbow Babies and Childrens Hospital, 11100 Euclid Ave., Mail Stop MTH6097, Cleveland, OH 44106. Telephone: (216) 844-8716. Fax: (216) 844-8233. E-mail: [email protected].
• Robert L. Wears, MD, MS, FACEP, Department of Emergency Medicine, University of Florida Health Center Jacksonville, 655 W. Eighth St., Jacksonville, FL 32209. Telephone: (904) 244-4124. Fax: (904) 244-4508. E-mail: [email protected].
The complete report Summary of Information submitted to MEDMARX in the Year 2001: A Human Factors Approach to Medication Errors (Item Number: 3MXDS01) costs $49. Shipping varies according to location. The report can be ordered on-line at The U.S. Pharmacopeia web site (www.usp.org). Click on "Products." Or contact Customer Service Department, 12601 Twinbrook Parkway, Rockville, MD. 20852. Telephone: (800) 227-8772 or (301) 881-0666. Fax: (301) 816-8148. For a list of recommendations for preventing pediatric drug errors, go to www.usp.org and click on "USP Issues Pediatric Recommendations."
PEPID ED is a portable medical and pharmacological database for emergency physicians. For more information, contact PEPID, 7344 N. Western Ave., Chicago, IL 60645. Telephone: (888) 321-7828. Fax: (773) 761-5011. E-mail: [email protected]. Web: www.pepid.com.
If you fail to implement effective systems to prevent pediatric medication errors, there can be liability risks for you and your facility.
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