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First Do No Harm — Avoiding Medication Errors in Children

Medication errors are especially problematic in children because many drugs are formulated for adults.

Medication errors are among the most common causes of adverse events in hospitalized patients. The Joint Commission on Accreditation of Healthcare Organizations recently issued a Sentinel Event Alert about the high risk for medication errors in children. Data reported in the April issue of Pediatrics demonstrated a mean of 11 adverse drug events per 100 randomly selected patients from 12 children’s hospitals, 16 events per 1000 patient-days, and 1 event per 1000 medication doses. Twenty-two percent of the errors were classified as preventable, and 2.5% led to patient harm.

Medication errors are especially problematic in children for a variety of reasons, including that many drugs are formulated for adults, many healthcare settings do not have reference materials or safeguards designed specifically for children, children have developmental differences in metabolization and excretion of drugs, proper dosing for children often requires additional calculation and fractional dosing with decimal points, and children might not be able to communicate adverse effects.

Recommendations from the Joint Commission to prevent pediatric medication errors include standardizing protocols for pharmacy ordering and timing of medications, ensuring equivalent home and hospital dosing of medications, using oral syringes for oral medications to avoid inadvertent intravenous administration, weighing patients in kilograms only, avoiding administering drugs based on estimated weight, and using error-proofing technology (e.g., bar coding, computer order entry).

Comment: These recommendations are relevant for both inpatient and outpatient settings. Among hospital therapies, chemotherapy and total parenteral nutrition pose particular challenges because of the complexity of the protocols. Not mentioned, but another important source of errors is illegible handwriting. All prescriptions should be printed by hand or computer.

— F. Bruder Stapleton, MD

Published in Journal Watch Pediatrics and Adolescent Medicine May 14, 2008

Citation(s):

Takata GS et al. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children’s hospitals. Pediatrics 2008 Apr; 121:e927.

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