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Drug Criteria & Outcomes
Suffer the children: Preventing medication errors in pediatric patients
By Sarita Bhat, Pharm.D candidate, Auburn (AL) University Harrison School of Pharmacy
Pediatric patients can be particularly vulnerable to medication errors, but tragedies like that described on a recent national news program can be averted if the factors that lead to such errors are understood and addressed by pharmacists and their clinical partners.
Many people viewed the 20/20 program on ABC at the end of March 2007 that described a young girl, who as an infant, received an anti-diabetic medication instead of her seizure medication.1 This error lead to her having more seizures for several weeks afterwards due to the dangerously low blood sugar levels that resulted from taking the wrong medication. She experienced permanent brain damage, and she now cannot take care of herself. This child has been permanently disabled because of a medication error that could have been prevented. Regardless of who was at fault in this particular case, a number of people are involved in the process of pediatric patients receiving their medication, and all of those people can take steps to prevent these permanently disabling or potentially fatal medication errors.
Before discussing the specifics as to who can do what in the process of receiving drug therapy, one must first understand why the pediatric population is so vulnerable to medication errors. Children present with a distinct set of risks, mainly that of a wide variation in body mass, body surface area, and organ system maturity, resulting in the need for individualized dosing for most drug therapies.2,3 This individualization involves calculations and sometimes special compounding of products, which leaves a larger margin for errors than a premixed product or a drug product with a set dose. Evidence has shown that harmful errors are three times more likely in children than in adults in the United States.2 Also, children are often unable to warn health care providers if they are about to get the wrong medication or if they are having an adverse drug effect.4
Wrong dose most common error
Errors varied between settings such as the pediatric intensive care units, emergency department, or an outpatient setting. Time of shift affected the rates of errors in a neonatal intensive care unit that was studied, as the day shift experienced more errors possibly due to the higher workload at that time.2 Examples of some of the types of errors seen included wrong dose (most common), drug, route, frequency, missed dose, wrong patient, or drug interaction. In one report, intravenous fluids were the most common product to be involved with medication errors in the pediatric population.3 According to another review, antibiotics and sedatives (benzodiazepines and barbiturates) were the most commonly implicated drug classes in which errors were made, most likely because these are widely prescribed in the pediatric population. The same review reported that there were more inaccuracies noted with medications that were not approved for use in children.2 Drugs with low therapeutic indices such as digoxin and phenytoin are more error-prone and require careful monitoring.5
Other environmental factors were also implicated in the barriers to patient safety, including fatigue, stress, anxiety, fear of blame, distractions, noise, poor lighting, lack of standardization of equipment or location of supplies.4 Particularly in emergency departments in many hospitals, medical residents with limited pediatric expertise are responsible for the majority of care of children, and many of these clinicians have had little to no previous training in pediatrics. Thus the dosing for this population is not familiar to them and moreover, there are no systems for verifying their competence at most facilities.
Based on trends in pediatric medication errors nationally, there are actions that may be taken to reduce the risk of fatal or permanently disabling pediatric medication errors in all departments of a health system or outpatient setting. One method that has been suggested is computerized physician order entry (CPOE), and it has proven to be effective in that the orders are complete, legible, and standardized.4 Additionally, robots and smart intravenous pumps have shown promise in reducing dispensing errors and would improve overall reliability of the system. Furthermore, the availability of practice guidelines and formatted templates at the physicians' fingertips would help gain pertinent and critical information from the patient. The role of clinical pharmacists on patient rounds may also have a significant impact on decision making for critically ill patients, but in reality everyone in a health care environment must be proactive to prevent pediatric medication errors from occurring, as listed in Table 1.2,3,5
An early focus of clinical education
If everyone involved in the medication use process for pediatric patients is properly educated with a quality assurance plan in place, along with a periodic review, then pediatric medication errors should be kept to a minimum, and health care costs will be reduced. This education may be implemented early in the careers of pharmacy students, nursing students, and medical residents. Studies have shown that although educational programs for medical residents and other medical staff have had an impact on reducing medication errors in pediatrics, implementing systems for prevention of errors are more important.5 Organizations such as The Joint Commission and the Leapfrog Group have been directing health systems to adopt these types of improvements.4 Parents should particularly be aware of their children taking sedative drugs in the outpatient setting, as severe harm is more likely to occur in this setting than the inpatient setting, since the patient is not directly monitored by a health care provider.6 If parents take an extra step in verifying their child's medication, then incidents such as the permanently disabling harm endured by the young girl described above will hopefully become nonexistent. Ultimately each individual involved in the well-being of an ailing child should take the responsibility to make sure that the child stays safe and recuperates.