The nation's first pediatric medication safety guidelines were issued by the Institute for Safe Medication Practices and the Pediatric Pharmacy Advocacy Group.
Even though the risk of medication errors is higher in children, hospitals haven't had a blueprint to help them shield their littlest patients against mistakes. That changed last month with the release of the first pediatric pharmacy medication safety guidelines.
The guidelines were produced by the Institute for Safe Medication Practices (ISMP) in collaboration with the Pediatric Pharmacy Advocacy Group (PPAG). The Society of Pediatric Nurses (SPN) has also endorsed the endeavor.
The groundbreaking guidelines cover everything from using computerized physician order entry (CPOE) to teaching math skills for dosage calculations to giving parents oral syringes at discharge. The guidelines address error prevention in the areas of organizational systems, such as CPOE and automated dispensing; healthcare professionals, including math calculations, and patient monitoring; and manufacturing and regulatory systems, such as safe pediatric dosages and bar-coding.
The guidelines are intended for children's hospitals, general acute care hospitals that admit pediatric patients, and ambulatory pediatric clinics. "We tried to bring everything together for all hospitals, not just pediatric institutions," said Stuart Levine, Pharm.D., director of pharmacy services, Alfred I. duPont Hospital for Children, Wilmington, Del. "In fact, it may be more of an issue for adult hospitals that see pediatric patients as a kind of sideline. We're concerned about pharmacists who don't have much pediatric background taking care of those patients."
Not only are children at greater risk of experiencing medication errors, the severity of those errors is three times higher in pediatric patients than in adults. There are several factors that contribute to the disparity. For one thing, clinical trials generally do not include children, and scant or no data are published about the nature, cause, and effect of drug reactions in children.
Pediatric patients may also have unique disease states, immature organs for drug elimination, or unique needs for drug administration. In the hospital, pharmacies have to pre-pare dosage forms with no standard compounding approach, and the pediatric medication use process requires more handling, preparation, and dosage calculations, which up the risk of errors.
Some of the suggested safety measures apply to all patient populations. Focusing on elimination of misplaced decimals and problematic abbreviations in orders, awareness of look-alike and soundalike drug names, and creation of a nonpunitive environment for reporting errors are safety measures every hospital should be implementing. But pediatric patients pose unique challenges that require extra precautions, said Levine, who updated draft guidelines that were produced in 1998.
One of the most critical areas is calculating dosages for patients who can range from a child of 28 weeks' gestation weighing less than 1,000 gm to a 100-kg teenager. "We're encouraging prescribers to indicate the milligram per kilogram per day or per dose on the inpatient or outpatient prescription," Levine said. "Then, whether you're the nurse on the patient floor or the outpatient pharmacist, you can check to be sure the dose is what was requested."
Review the original medication order before dispensing, unless emergency circumstances dictate otherwise. Screen for prescribing errors, allergies, drug and disease interactions, correct dose, and indication. Check dosage calculations against acceptable dosage ranges. Contact the prescriber of a questionable order for clarification before dispensing. Compare the original order with the label and the product before it is dispensed.
Dispense meds for individual patients in premeasured, ready-to-administer form, whenever possible. When that's not possible, use auxiliary labels to clearly communicate preparation instructions prior to administration.
Carefully document products used and steps and calculations performed when a drug is prepared or manufactured. This is primarily for high-alert drugs, those with the greatest consequences of error. For such drugs, it is particularly important that an independent double check be used for all calculations.
Carefully document all oral orders received from prescribers as new orders, renewals, or corrections to a new order. Document immediately after receiving and carefully verifying the order by repeating it back to the prescriber. In addition, spell the drug names and any other words that might be misheard and restate numbers that may be confused, such as those in the teens.
Source: The Journal of Pediatric Pharmacology and Therapeutics, "Guidelines for Preventing Medication Errors in Pediatrics"
Carol Ukens. Pediatric groups hail new med safety guidelines. Drug Topics 2002;14:HSE34.