On-floor pharmacists may reduce pediatric ADEs

No. 1 error in pediatrics: Dosage calculations

The smallest patients often are the ones most affected by medication errors, according to a recent study published in the Journal of the American Medical Association.1 Most of the errors, however, can be prevented by having ward-based clinical pharmacists, the authors say.

In the study, titled "Medication errors and adverse drug events in pediatric inpatients," researchers reviewed 10,778 medication orders at a children’s hospital and the pediatric wards of a general hospital. They found 616 medication errors, 115 potential adverse drug events (ADEs), and 26 ADEs. The rate of potential ADEs was three times that found in a 1992 study conducted in an adult patient population, with the neonates carrying the highest risk, the study says. Most potential ADEs occurred at the stage of drug ordering (79%) and involved incorrect dosing (34%), anti-infective drugs (28%), and intravenous medications (54%).

Having clinical pharmacists on work rounds could lead to physicians making more informed clinical decisions and could prevent some of the errors, the researchers say. The researchers also recommend that clinical pharmacists assume leadership in error-prevention activities in pediatric wards, including:

  • monitoring the transcription of medication orders;
  • developing drug therapy protocols; and
  • overseeing drug preparation and storage.

Weight-based dosages

The No. 1 error in pediatrics is dosage calculation, says Helen Fiechtner, PharmD, pediatric clinical pharmacist at Sioux Valley Hospital and professor of clinical pharmacy at South Dakota State University in Sioux Falls. Calculating weight-based doses for pediatric patients can be tricky, especially if the patients weigh less than 1 kg. Pediatricians and neonatologists usually are careful about choosing a dose, she says, but other doctors sometimes just guess. She also has seen physicians use the wrong weight when they do calculations in their heads. "They know the right dose but they have the wrong weight. Then the nurse transcribes it," Fiechtner says.

A pediatric medicine safety practice survey conducted last year by the Institute for Safe Medicine Practices (ISMP) in Huntingdon Valley, PA, and the Pediatric Pharmacy Advocacy Group in Littleton, CO, found that 75% of respondents reported prescribers often or consistently failed to include the dosage equation on the order.2 The survey also showed that only 50% of pharmacists consistently verified the mg/kg dose and double-checked the math involved, regardless of the setting of care.

Proper education in pharmacy schools could help with this problem, Fiechtner says. "A lot of schools don’t do a good job of teaching about pediatrics. They don’t always stress the importance of checking all the doses." In her hospital, every dose has to be checked manually in mg per kg. This does not happen often in retail, however, she says. "Some pharmacists in a retail setting don’t have a weight, so they can’t check the dose." (See ISMP’s web site for medication error prevention strategies at www.ismp.org/MSAarticles/PedsSurvey.html.)

Working on risk prevention

Fiechtner has been involved in risk management at her facility since she began working there 10 years ago. Another member of the clinical faculty is in charge of the medication error program, which is a nonpunitive system. Now all orders are double-checked in the pharmacy, and narcotics doses are double-checked by a nurse. When nurses arrive for their shifts, they must manually check the hanging drips and IVs. "We calculate all of the doses to ensure that the pumps are programmed correctly," Fiechtner says. "The nurses can’t assume that the nurses prior to them did it right. We have caught errors before they have gone on for a long time."

Fiechtner and her colleagues also have developed different protocols for the use of certain medications, especially medications that nurses aren’t familiar with. Fiechtner realized the hospital had no policy to safeguard children when she walked into the pediatric intensive care unit and saw someone administering a risky drug to a child. The child had no complications, but Fiechtner and her colleagues started writing guidelines to make sure that particular drug was administered safely. "We wanted to prevent the risk," she says. "The nurses are now getting better at identifying risky situations."

Fiechtner is able to work on the floor, but she knows other hospitals cannot afford to hire an extra pharmacist to assist in the pediatric units. "Some hospitals may not have big pediatric or nursery populations, and their pharmacies are in the basement," she explains. "Now it’s a manpower issue. It’s hard for hospitals to add people to do that."


1. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse events in pediatric inpatients. JAMA 2001; 285:2114-2120.

2. Institute for Safe Medication Practices. ISMP Medication Safety Alert; 2000. Available at www.ismp.org/MSAarticles/PedsSurvey.html


Helen Fiechtner, PharmD, pediatric clinical pharmacist at Sioux Valley Hospital and professor of clinical pharmacy at South Dakota State University in Sioux Falls. Telephone: (605) 333-7362.