In the News: Pediatric Medication Safety

With the recent news release and attention focused on pediatric medication errors, it is important to assess staff competency and knowledge of medications and medication calculations for all ages of patients.  As reported by the Joint Commission children are at a greater risk for medication errors. This increased risk occurs at a rate of three pediatric errors to one adult error.  Key to this statistic are the risks associated with medication calculations and the high-risk medications that have a greater potential for adverse reactions.  Children are at a greater risk for medication adverse reactions due to their smaller body mass and the incomplete development of their body organs and defense systems.  Another problematic area relative to pediatric patients is the child’s level of understanding and ability to express adverse affects that they might be experiencing.  An increased risk also occurs with special volumes or concentrations of medications, as these pose a greater danger than premixed pediatric single-dose delivery systems.

Most of the harmful pediatric medication errors tracked during the past two years by U.S. Pharmacopeia involved either an improper dose or quantity [JointCommission.4/08].  With every needed measurement or calculation, there is a risk for an incorrect calculation, error or misinterpretation.  The use of kilograms rather than pounds for body weight is another potential source of error, especially for infants and children.

Contained within the recently released Joint Commission’s Sentinel Event Alert are steps to take to reduce the risks associated with pediatric medication dosages and care.  With summer approaching and special outdoor and bereavement camp offerings, now is a good time to access this alert and identify key strategies to initiate in order to reduce associated risks.  In addition, many of the actions suggested within the Sentinel Event Alert are also applicable to adult medication administration.

Examples provided include the establishment of available resources, both online and within the organization’s printed matter, specific to pediatric administration, calculations and a listing of known high-risk pediatric medications.  Pediatric textbooks or references that provide growth and developmental norms, growth charts [height and weight], normal vital sign ranges that are age specific, in addition to drug reference materials should be included in these resources.  In addition policies should establish specific protocols and procedures to follow for first dose pediatric medication administration, as well as ongoing pediatric medication therapy regimens.

Providers who routinely care for the pediatric population should hire staff with core pediatric nursing competencies who have passed a written pediatric dosage calculation examination.  These staff should be assigned to not only care for pediatric age patients but to also case manager the pediatric age patient’s care.

As part of the routine and accepted documentation of the provider, it is important to avoid the abbreviations noted as “do not use” abbreviations and to record accurately and legibly all documentation, including medication orders, calculations and administrations.

For more information on the risks associated with pediatric and medication errors and steps that can be taken to reduce associated risks for all ages of patients, several online databases and resources were noted in this media release and the Sentinel Event Alert.  More information can be found at the Joint Commission International Center for Patient Safety’s website http://www.jcipatientsafety.org/ or by accessing http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm for the complete Sentinel Event Alert.