MEDICATION ERRORS IN PEDIATRICS

HATEM S. EL-DABBAKEH, BSN, MPH, Dr.PH-Epidemiology

NOTES, CAUSES, AND PREVENTION

Key Definitions (1)

Adverse drug reaction (ADR) A noxious and unintended response to a medicine that occurs at normal

therapeutic doses used in humans for prophylaxis, diagnosis, or therapy of disease, or for the modification of physiologic function

The word “effect” is used interchangeably with “reaction.”

Side effect Any unintended effect of a pharmaceutical product occurring at normal

therapeutic doses and is related to its pharmacological properties. Such effects may be well-known and even expected and require little or no change in patient management.

Serious adverse effect Any untoward medical occurrence that occurs at any dose and results in

death, requires hospital admission or prolonged hospital stay, results in persistent or significant disability, or is life threatening

Key Definitions (2)

Prescribing error Incorrect medicine ordering by a prescriber

Medication error Administration of a medicine or dose that differs from the

written order

Negligence Medical decision making or care below the accepted

standards of practice

Medication Errors in General

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Definition: An error in prescribing, dispensing, or administering a medication

Data suggests medication errors are seen at a higher rate in the ED than other areas of the hospital

Medication errors positively correlate with inexperience, and with stress/fatigue

Sedation and resuscitation are especially vulnerable to errors

It is suspected that medication errors are underreported

Medication Errors (1)

Administration of medicine or dose that differs from written order Medicine prescribed but not given Administration of a medicine not prescribed Medicine given to the wrong patient Wrong medicine or IV fluid administered Wrong dose or strength given Wrong dosage form given

Medication Errors (2)

Medicine given for wrong duration Wrong preparation of a dose (e.g., incorrect

dilution) Incorrect administration technique (e.g., unsterile

injection) Medicine given to a patient with known allergy Wrong route of administration used Wrong time or frequency of administration

Causes of Medication Errors

Human factors Heavy staff workload and fatigue Inexperience, lack of training, poor handwriting, and oral

orders

Workplace factors Poor lighting, noise, interruptions, excessive workload

Pharmaceutical factors Excessive prescribing Confusing medicine nomenclature, packaging, or labeling Increased number or quantity of medicines per patient Frequency and complexity of calculations needed to prescribe,

dispense, or administer a medicine Lack of effective policies and procedures

Dosing Errors in Children8

Current research shows that, in pediatrics, dosing errors are the most common type of medication error due to:

Lack of standard doses for many drugs (often off label) used in children

Individual doses based on age, weight or body surface area require calculations that are prone to failure (even in ideal settings) Tenfold errors are common dosing errors, and are often associated

with higher toxicity than other types of dosing errors Failure to correctly estimate a child’s weight continues to be a

common problemCASE: Jose Martinez was a 2-month-old who exhibited early signs of CHF. His physician ordered IV Digoxin over an extended length of stay. However, due to a decimal point error, Jose received a dose that was 10 times what was intended. Jose died.

Medication Errors in the ED

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A recent study involving medication administration in a simulated pediatric emergency scenario revealed numerous

opportunities for nursing performance improvement:

a. Communication – 45% orders were not verbally repeated back

b. Converting Dose –14.2% converted incorrectly (convert mg into ml)

c. Selecting medication – 7.3% wrong vials selected

d. Dilution & reconstitution – 40% Ceftriaxone not properly constituted

e. Measuring Dose – 32.7% measured doses ≠ to intended dose

Medicine Ordering or Prescribing

Transcribing

Dispensing

Administering

Monitoring

MEDICATION ERROR

When Medication Errors Occur (1)

Preventing Medication Errors (1)

Establish consensus group of physicians, nurses, and pharmacists to select best practices

Introduce a punishment-free system to collect and record information about medication-related errors

Develop written procedures with guidelines and checklists for IV fluids and high-risk medicines (e.g., insulin, heparin, narcotics)

Preventing Medication Errors (2)

Require legible handwriting and complete spelling of medicine name

Use standardized notation Doses given in mg, mcg, g Leading zero used for values < 1 and no trailing zero (e.g., 0.2

mg instead .2 mg; 2 mg instead of 2.0 mg)

Write route of administration on all orders

Write out directions completely (e.g., “daily” not “QD” or “OD”)

Preventing Medication Errors (3)

Limit use of telephone and oral orders to emergency situations

Confirm identity of patients before administering medication

Use standard administration times for hospitalized patients

For look alike and sound alike names, establish a policy requiring that prescribers write both brand and generic names

Use pharmacy staff to help prevent errors

Nursing Student Responsibility (1)

Follow all Hospital’s or department’s policies and procedures especially those related to Patient Safety.

Nursing Student Responsibility (2)

Nursing students do not take verbal/telephone orders from physicians

Nursing students do not administer any chemotherapy agents (oral or IV)

Nursing students do not give IV push medications EVER!

Nursing students do not administer narcotics, paralytics, or vasopressors via pump or drip

Nursing students may not independently program any infusion pumps

1. Student must give medication under the direct supervision of a nursing instructor unless supervision has been prearranged with the instructor and the RN/BSN caring for your patient.

2. When giving a scheduled med late you must document the actual time given.

3. If a scheduled med is not given you must document not given and document the reason why..

4. You must have medications cosigned by an instructor or the RN/BSN caring for the child

Medication administration documentation (students)

Faculty Responsibility…

Directly supervise the administration of medications. When the student has demonstrated adequate knowledge and good technique, s/he may give medications (except IV meds) with staff nurse availability. This must be pre-arranged between the faculty and staff BSN.

All student medication administration is to be directly supervised by clinical faculty or staff nurse. The supervising BSN (faculty or staff BSN) will co-sign the MAR.

RN/BSN reviews and co-signs documentation and medication administration. Writes “I agree/concur with above documentation” and/or add any additional documentation. (Note: LPNs may not co-sign RN/BSN student nurse medication administration documentation).

Some hints from the wise

Always check name band prior to giving any medications.

Always check to see that ordered dose is appropriate based on weight.

Always look up medications unfamiliar to you before leaving the medication room.

Wow, that is a lot of to do’s and not to do’s…but ultimately keeping

kids safe is our goal!

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“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

- Johann von Goethe

Thanks!

Medication errors in PediatricsPresented by HATEM S. EL-DABBAKEH, BSN, MPH, Dr.PH-

Epidemiology