Joint Commission Alert: Prevent Pediatric Medication Errors - Children Are Three Times More At Risk Than Adults

Main Category: Litigation / Medical Malpractice
Also Included In: Pediatrics / Children's Health
Article Date: 14 Apr 2008 - 1:00 PST

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Medications specifically made for adults and administered to children in health care facilities are putting young patients at greater risk for drug errors, according to a Joint Commission alert issued today to improve pediatric safety.

The Joint Commission's latest Sentinel Event Alert addresses pediatric medication errors, and urges greater attention to precautions such as medication standardization, improved medication identification and communication techniques, as well as the use of kilograms as the standard weight measurement to calculate proper dosages.

Most of the harmful pediatric medication errors tracked during the past two years by U.S. Pharmacopeia involved either an improper dose or quantity, according to the Alert. Problems typically arise when hospitals and clinics are forced to prepare special volumes or concentrations because the drugs are formulated and packaged primarily for adults. The need to alter the original medication dosage requires a series of calculations and tasks that increase the chance for error.

"Children often lack the communication skills to tell caregivers if something is wrong, which increases the responsibility of caregivers to carefully monitor their care to keep them safe," says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. "Organizations and caregivers must commit themselves to using effective risk reduction strategies to make a difference in preventing pediatric medication errors."

To reduce the risk of pediatric medication errors, The Joint Commission's Sentinel Event Alert suggests that health care organizations take a series of specific actions, including:

- Use the Joint Commission's National Patient Safety Goals and Medication Management Standards to guide safe medication practices for pediatric patients;

- Weigh all pediatric patients in kilograms, which then becomes the standardized weight used for prescriptions, medical records and staff communication;

- Do not dispense or administer drugs classified as high risk until the patient has been weighed, unless it is an emergency situation;

- Require prescribers to write out how they arrived at the proper dosage, as dose per weight, so that the calculation can be double checked by a pharmacist, nurse or both; and

- Use pediatric-specific medication formulations and concentrations when possible.

The Alert also encourages organizations to be open and transparent if an error occurs in order to facilitate learning so that future errors can be prevented; drug manufacturers to develop pediatric-specific formulations and to standardize labeling and packaging of all medications; and parents to seek out information and ask questions about their child's medications and to repeat back instructions to health care professionals in order to avoid mix-ups.

The warning about pediatric medication errors is part of a series of Alerts issued by The Joint Commission. Information and guidance provided in these Alerts is drawn from The Joint Commission's Sentinel Event Database, a comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about adverse events and their underlying causes. Previous Alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides. The complete list and text of past issues of Sentinel Event Alert can be found on The Joint Commission website.

Joint Commission International Center for Patient Safety