Pharmacists say more needs to be done to prevent pediatric medication errors

The Joint Commission issues a sentinel event alert to warn hospitals about drug errors involving kids

Health-system pharmacists responded favorably to a recent Joint Commission (JC) Sentinel Event Alert that addressed the problem of pediatric medication errors. But some pharmacists admit that there's a long way to go before medications made for adults and administered to children will be a thing of the past.

The JC alert recommended pediatric-specific strategies for reducing medication errors including paying greater attention to precautions such as medication standardization, improved medication identification and communication techniques, and the adoption of kilograms as the standard weight measurement to calculate dosages. The Joint Commission lists other risk reduction strategies at

"This alert calls for hospitals to weigh the pediatric patients in kilograms and this should become the standard for reporting pediatric patient weight," said Peter Angood, M.D., VP and chief patient safety officer at the JC at a press conference last month.


Some hospitals are turning to technology as a way of addressing the issue of standardized concentrations. Elora Hilmas, Pharm.D., pharmacy residency coordinator at the Alfred I. DuPont Hospital for Children in Wilmington, Del., is one of the patent holders for Pharmacy OneSource's Accupedia, which optimizes accurate pediatric drips based upon standardized concentrations and fluid loads. The software program allows users to order continuous infusion without using an antiquated Rule of 6 method of determining concentrations (see Drug Topics, May 22, 2006).

Under the category of full pharmacy oversight, the JC recommends the development of preprinted medication order forms and clinical pathways or protocols to reflect a standardized approach to care. Hilmas said that preprinted medication order forms are critical because there will be a huge push toward computerized physician order entry (CPOE). "Having these things in place now will ensure patient safety for pediatric patients and then help when they transition to CPOE."

The JC alert also urges hospitals to use technology judiciously. "Smart pumps are the last level of check before a medication is infused. If the drug library is not built properly, you are not getting the true benefits of a smart pump. It has to be built with the appropriate safeguards and be used properly by nurses."

At Swedish Medical Center in Seattle, the focus on pediatric training extends beyond pharmacists and nurses to pharmacy technicians. "At Swedish we have a subset of pharmacy technicians who are specifically trained in pediatrics. They are very cognizant of what pediatric errors might occur," said Nancy Nugent, R.Ph., a pediatric pharmacist at Swedish Hospital.

Health-system pharmacists, especially those who work in children's hospitals or in facilities with a sizable pediatric patient population, assert that they have been trying for years to push through some of the safeguards outlined in the JC's alert. Some pharmacists complain that it often takes a high-profile pediatric medication error before the public is made aware of the extent of the problem, such as the accidental overdose of the blood thinner heparin for actor Dennis Quaid's twin infants. "For years we have been complaining about the labeling of heparin vials because they look so similar. Hopefully now a change will take place," said Hilmas. "I think with technology and CPOE and safety checks to help with medication calculations, we are going to make a lot more progress in the future."

THE AUTHOR is a writer based in New Jersey.