* Eliminate barriers to reporting adverse medication events36,42,43 and encourage a nonpunitive culture for reporting and review of adverse events.15,36,42,43 Ensure that all staff members understand the method for reporting and are knowledgeable in JCAHO-mandated reporting rules.7 Reporting systems should follow the guidelines outlined in the AAP policy statement “Principles of Patient Safety in Pediatrics,”25 which focus on system error root cause analysis. Reason9 stated that humans are imperfect, and errors should be expected. Tenfold errors in pediatric doses are not uncommon. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Thank you for your interest in spreading the word on American Academy of Pediatrics. 2005;105(5):79-84. Ensure that patient identity has been checked before medication administration. Ensure that dosing intervals are followed as prescribed. If verbal orders are to be used, spell out common error words (eg, fifteen vs fifty). 3 Structured questionnaires were distributed to 75 nurses, and 50 nurses completed them. Avoid abbreviations of drug names (eg, MS may mean morphine sulfate or … Use generic medication names rather than trade names. Pediatrics. Only 0.2% of all errors made during the study period reached the patient owing to interventions made by the pediatric pharmacists, which shows a … Medication Errors Symposium White Papers. In addition, there are few standardized dosing regimens for children, with most medication dosing requiring body weight calculations. Medication errors can have serious and costly consequences, such as increased patient lengths of stay, additional medical interventions, serious harm, or even death. 5600 Fishers Lane This newly released Sentinel Event Alert focuses on pediatric medication errors, in light of recent data demonstrating that such errors are more common than previously thought and may not be prevented by standard medication error preventive measures. 5. Patient Fact Sheet: 20 Tips to Help Prevent Medical Errors in Children. It is incumbent on hospitals to include such programs in their policies and procedures to decrease the risk of prolonged hospitalization and attendant errors associated with drug treatment. Maintain medication profiles for inpatients and ambulatory patients receiving care at the hospital, with updated allergy histories with each encounter. 1. 2008; 39:1-4. * Develop prospective error tracking systems run on a consistent basis to target and monitor common pediatric errors. You may see some delays in posting new content due to COVID-19. Us, Medication Errors/Preventable Adverse Drug Events. An example is for adjustment of dose or dosing interval for neonates or for body surface area. Examples include total parenteral nutrition preparation sites, oncology satellite pharmacy, and anesthesia tray preparation and dispensing.51. A medication error is an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. Verify drug orders before medication administration. Ask questions about the purpose of each medication to be used. ADEs in hospitalized patients will result in longer hospital stays and extra medical costs, even though they are s… Inform physicians and hospital staff about prescribed or over-the-counter medications the child is taking. Rockville, MD 20857 ... First, do no harm: Reducing pediatric medication errors: Children are especially at risk for medication errors. Recheck drug compatibility with existing medication list, and check for current allergy history. Nurses should be familiar with the potential for errors of medication administration records, pyxis, and other automated devices. Prepare drugs in a clean and orderly work area with minimal interruptions. Policy, U.S. Department of Health & Human Services. Experts agree that medication errors have the potential to cause harm within the pediatric population at a higher rate than in the adult population. Preventing pediatric medication errors. Encourage blame-free error reporting. Avoid vague instructions (eg, “take as directed”); make instructions specific (eg, “take 1 tablet each morning”). The Agency for Healthcare Research and Quality states that the single most important thing families can do to prevent medical errors is to actively participate in the child's health care.59 Nurses can involve the family whenever administering a medication and inform worried parents by taking the time to state the name of the medication, discuss why the medication is being administered and explain the dose, … Use a zero to the left of a dose less than 1 (eg, use 0.1 rather than .1) to avoid 10-fold dosing errors. Where possible, use clinical pharmacologists to review procedures and orders.11,50. Rinke ML, Bundy DG, Velasquez CA, et al. April 11, 2008, Preventing Pediatric Medication Errors). 6. 6 In community hospital emergency departments unaccustomed to dealing with pediatric patients, medication errors may be much higher. Prescriber Update 36(1): 14 March 2015. Errors associated with medications are believed to be the most common type of medical error and are a significant cause of preventable adverse events. Providing drug treatment in the hospital setting requires that a series of actions be performed correctly by several members of the health care team, such as the physician, the unit clerk, the hospital pharmacist, and the nurse. Advances in clinical therapeutics have resulted in major improvements in health for patients with many diseases, but these benefits have also been accompanied by increased risks. Prevention of medication errors in the pediatric inpatient setting. Updates, Electronic Stucky ER; American Academy of Pediatrics Committee on Drugs; American Academy of Pediatrics Committee on Hospital Care. When possible, speak with the patient or caregiver about the medication that is prescribed and any special precautions or observations that should be noted, such as allergic or hypersensitivity reactions. 6. Email Avoid use of a terminal zero to the right of the decimal point (eg, use 5 rather than 5.0) to minimize 10-fold dosing errors. Using medication reconciliation to prevent errors. Koren G(1), Haslam RH. Sentinel event alert. Responding to the key messages in earlier volumes of the series— To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004) —this book sets forth an agenda for improving the safety of medication use. Results of Pediatric Medication Safety Survey (Part 1) Institute for Safe Medication Practices Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Providing pharmacy services to the pediatric population presents unique challenges to the pharmacist. Author information: (1)Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada. When a patient or parent or caregiver questions whether a drug should be administered, listen attentively, answer questions, and double-check the medication order. Most medications used in the care of children are formulated and packaged primarily for adults. * Stay current and knowledgeable concerning changes in medications and treatment of pediatric conditions. MEs in hospitalized children occur in all medication processes and mainly involve dosing errors. Enter multiple addresses on separate lines or separate them with commas. 34. Where available, integrate clinical pharmacists into patient care rounds50,52,53 with physicians and nurses, particularly in intensive care and oncology units. Pediatric Medication Errors: Predicting and Preventing Tenfold Disasters. In general, the number and severity of adverse medication reactions are directly related to the number of drugs administered to hospitalized patients.2–4 In contrast to these nonpreventable adverse drug reactions, medication errors occur as a result of human mistakes or system flaws. Scope of Medication Errors • Each year in the U.S., serious preventable medication errors occur in 3.8 million inpatient admis-sions and 3.3 million outpatient visits.2,3 • The Institute of Medicine, in its report To Err Is Human, estimated 7,000 deaths in the U.S. each year are due to preventable medication errors.4 Costs of Medication Errors Inform physicians and hospital staff about a child’s use of complementary or alternative methods of health maintenance or therapeutic treatments, including herbal or dietary supplements. * Standardize equipment throughout the institution, such as infusion pumps and weight scales.32, * Standardize measurement systems throughout the institution, using for example only kilograms for weight rather than pounds or kilograms in different areas within the institution.32. Remain familiar with the operation of medication administration devices and the potential for errors with such devices, particularly patient-controlled analgesia or infusion pumps. Globally, the cost associated with medication errors … Writing Act, Privacy Medication errors can happen to anyone in any place, including your own home and at the doctor's office, hospital, pharmacy and senior living facility. The importance of parents in preventing inpatient medication errors is uncertain. Encourage use of methodology for error and prospective data analysis and tracking, such as plan-do-check-act/plan-do-study-act format and evidence-based medicine36 review. Review the patient’s existing drug therapy, including any over-the-counter medications or herbal or dietary supplements, and inquire about old and new allergies before prescribing medications. Your doctor can help prevent medication errors by using a computer to enter and print (or digitally send) any prescription details, instead of hand writing one. A prior study documented the types of medication errors at an academic children's hospital and explored means of preventing such errors. Encourage patients and families to ask questions about all medications ordered. Pediatricians should help hospitals develop effective programs for safely providing medications, reporting medication errors, and creating an environment of medication safety for all hospitalized pediatric patients. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Preventing adverse events caused by emergency electrical power system failures. Dose range limits and sound-alike errors are examples.36,38 As part of this tracking system, encourage reporting of even minor errors whether or not they have been corrected or are of minimal clinical significance. Background and objective: Medication errors cause appreciable morbidity and mortality in children. The objective was to determine the effectiveness of interventions to reduce pediatric medication errors, identify gaps in the literature, and perform meta-analyses on comparable studies. surveyed pediatric nurses working in a public hospital to examine their experience with medication administration errors. * Develop and maintain a process for informing families of errors. “Preventing Pediatric Medication Errors” learning module is a home-study, knowledge activity for health-system pharmacists. The effort to prevent neonatal and pediatric medication errors involves the creation of a “culture of safety,” with a shift in focus from counting the number of errors that occur to developing process-oriented and actionable preventive strategies. Healthcare professionals and parents/carers have the opportunity to help reduce paediatric medication administration errors. Research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness. Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health. AJN. Prevention of medication errors in the pediatric inpatient setting. CONCLUSIONS. Sentinel event alert. Strategies should be developed to prevent MEs as these still threaten medication safety in pediatric inpatients. Do not store look-alike or sound-alike medications adjacent to one another. Interventions to reduce pediatric medication errors: a systematic review. The alert highlights the importance of dosing errors (eg, weight-related and calculation-related errors), as well as the fact that technology used to reduce medication errors in adults must be adapted for children. 3 Structured questionnaires were distributed to 75 nurses, and 50 nurses completed them. Preventing pediatric medication errors Errors associated with medications are believed to be the most common type of medical error and are a significant cause of preventable adverse events. Even before the Institute of Medicine reported on medical errors in 1999, the American Academy of Pediatrics and its members had been committed to improving the health care system to provide the best and safest health care for infants, children, adolescents, and young adults. Preventing Medication Errors in Pediatrics The Pediatric Pharmacy Advocacy Group is a non-profit professional pharmacy association dedicated to improving the healthcare of all chil-dren. * Establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection, and therapeutic use. Koren G(1), Haslam RH. Fortunately, only a few of these errors actually reached the patient. Preventing errors relating to commonly used anticoagulants. Be responsible for knowing medication names, strengths, and dosing. Are Parents Who Feel the Need to Watch Over Their Childrens Care Better Patient Safety Partners? * Develop and maintain continuous education programs for nursing competencies in devices used for pediatric medication administration, particularly patient-controlled analgesia and infusion pumps. Or Sign In to Email Alerts with your Email Address, Prevention of Medication Errors in the Pediatric Inpatient Setting, What causes prescribing errors in children? Medication errors in pediatric inpatients: a study based on a national mandatory reporting system. Policies, HHS Digital Telephone: (301) 427-1364. Ensure that calculations are correct. Of these, adverse reactions to medications include those that are usually unpredictable, such as idiosyncratic or unexpected allergic responses, and those that are predictable, such as adverse effects or toxic reactions related to the inherent pharmacologic properties of the drug. * Recheck calculations and ensure dose ordered falls within accepted pediatric weight-based dose ranges. In order for … A medication error is any preventable event that occurs in the process of ordering or delivering a medication, regardless of whether an injury occurred or the potential for injury was present.1,5–7 The distinction between the 2 is salient; an allergic reaction to a medication can be an adverse reaction if there is no history of patient allergy, yet can be a medication error in that same case of allergic reaction if the patient did have a documented history of allergies but that medical information was not available, not consulted, or overlooked.1 Even more important to emphasize is that medication errors can occur in the absence of injury to the patient. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Avoid use of verbal orders whenever possible. * Standardize order sheets to include areas for patient weight, old and new allergies, prescriber name, signature, and contact number. Enter the password that accompanies your email address. The definition of adverse drug events (ADEs) is any injuries to a patient resulting from medication use, including any harm or loss of function. Department of Health & Human Services. Kids are especially at high risk for medication errors because they typically need different drug doses than adults. This is important to provide family-centered care and commitment to quality. The process of drug absorption, distribution, metabolism, and elimination is referred to as pharmacokinetics.3 It is important to recognize differences in the factors that affect drug disposition in children. Therefore, medications often must be prepared in different volumes or Physician prescriptions and drug orders are a means of communicating, so they must be legible, clear, and unambiguous. Sites, Contact Many medication errors and subsequent adverse reactions that occur in children are preventable. Interventions to reduce pediatric medication errors: a systematic review. Dispense medication in a timely fashion using a unit-dose, ready-to-administer form whenever possible. The following steps help ensure that medication orders communicate safely and effectively. The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Three interventions might have prevented most potentially harmful errors: 1) computerized physician order entry with clinical decision support systems (76%); 2) ward-based clinical pharmacists (81%); and 3) improved communication among physicians, nurses, and pharmacists (86%). 2008;39:1-4. Pediatric medication errors: predicting and preventing tenfold disasters. Participate in medication reconciliation Asking questions is essential, but it isn't enough. Review a copy of the original written medication order before dispensing a medication, except in emergency situations. surveyed pediatric nurses working in a public hospital to examine their experience with medication administration errors.3 Structured questionnaires were distributed to 75 nurses, and 50 nurses completed them. 3 Oshikoya et al. Preventing pediatric medication errors. eBroselow is dedicated to developing a simple, safe, and effective international standard for acute drug administration. Preventing medication errors in pediatric patients poses unique challenges for healthcare providers. For adults, the reported incidence of errors in treatment with medications ranges from 1% to 30% of all hospital admissions,8 or 5% of orders written.5 In pediatrics, however, this number has been reported to be as high as 1 in 6.4 orders.9 A 1995–1999 study by the US Pharmacopeia (USP) Medication Errors Reporting Program demonstrated a significantly increased rate of medication error resulting in harm or death in pediatric patients (31%), compared with adults (13%).10 In a more recent study, ADEs occurred at a similar rate between pediatric (5.7%) and adult patients (5.3%). Learn your institution’s medication administration policies, regulations, and guidelines. Key Messages . 12. 5. Scoping review, Parent Perceptions of Real-time Access to Their Hospitalized Childs Medical Records Using an Inpatient Portal: A Qualitative Study, Priorities for Pediatric Patient Safety Research, Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care, Pediatric Readiness in the Emergency Department. Remain available to prescribers and nurses to participate in drug therapy development and monitoring. Record and verify patient identity, weight, allergies, and previous medication use. The safe administration of medications to hospitalized infants and children requires additional safeguards that are above and beyond those for adult patients. The American Academy of Pediatrics (AAP) is committed to decreasing medication errors in the treatment of children24 and to the development of systems designed to identify and learn from errors.25 Children vary in weight, body surface area, and organ system maturity, which affect their ability to metabolize and excrete medications. About eBroselow Be aware of and involved in ongoing error-tracking systems and pharmacy programs. The Joint Commission published a Sentinel Event Alert in 2008 to address the prevention of pediatric medication errors and noted that most healthcare settings are primarily built around the needs of adults. * Utilize pharmacist consultation if available. The costs for such system overhauls is significant, but a change is now being demanded by legislators and families.33 The business community, the Medicare Payment Advisory Commission,34 the Agency for Healthcare Research and Quality,35 and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)7 acknowledge the need for system overhaul. The Institute of Medicine (IOM)1 defines an adverse drug event (ADE) as an injury resulting from medical intervention related to a drug, which can be attributable to preventable and nonpreventable causes. An official website of the Campaign to Address Pediatric Medication Dosage Errors. National and state legislative actions have heightened public awareness of these events. We do not capture any email address. * Develop and maintain pediatric medications knowledge base. Confirm patient identity, comparing order written to information available in the pharmacy system. They should also be tied to laboratory and adverse event reporting systems. Provide education to patients or caregivers about their medications. Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Preventing Medication Errors is the newest volume in the series. Reporting medication errors is problematic due to fears of reprisal, intimidation, or disciplinary actions.3 Oshikoya et al. * Develop institution-specific lists of pediatric drugs for drug-use evaluation and of high-risk drugs requiring cross-checks in concert with other hospital and medical staff. Origins of and solutions for neonatal medication-dispensing errors. * Communicate concerns and questions related to past or present medication administration to providers, including any developmental or behavioral barriers to successful medication administration. Note any old and new allergies on orders. Author information: (1)Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada. Hospitalized infants and children are subject to advantages and risks of inpatient care. To sign up for updates or to access your subscriber preferences, please enter your email address * Develop an educational program for all hospital and medical staff in calculating, prescribing, preparing, and administering medications for children.9,10,39–41. Use a zero to the left of a dose less than 1 (eg, use 0.1 rather than .1) to avoid 10-fold dosing errors. This profile may include current and past-year medications lists, adverse drug reactions history, pharmacokinetics, and allergies. 6 In community hospital emergency departments unaccustomed to dealing with pediatric patients, medication errors may be much higher. Spell out dosage units rather than using abbreviations (eg, milligram or microgram rather than mg or μg; units rather than U). 34 Neither a robot nor a paediatric unit-dosing system would have prevented the overdose error described in the second case. surveyed pediatric nurses working in a public hospital to examine their experience with medication administration errors. Human and device errors can lead to preventable morbidity and mortality. * Confirm that the patient’s weight is correct for weight-based dosages. Included in most medical and surgical treatment regimens for hospitalized pediatric patients is administration of medications that may be associated with undesirable as well as therapeutic effects. Unusually large or small volumes or dosage units for a single patient dose should be verified. Recommendations uniquely pertinent to children are noted with an asterisk (*), and more general recommendations are noted with a bullet (•). Dr. Gideon Koren MD, ABMT, FRCPC. To Err Is Human: Building a Safer Health System. When possible, bring all current medications to the hospital for confirmation and review. Inform physicians and hospital staff of any old and new allergies. Preventing Pediatric Medication Dosing ... SafeDose has proven to eliminate errors and extra steps in medication preparation and administration in real-world settings and goes a long way toward ensuring medication administration safety in pediatric emergencies. Ensure that all staff members understand the method of reporting and are knowledgeable about JCAHO reporting rules.7. Therefore, medication error improvement programs must focus on system improvements and team communication. * Where reasonable, computerize systems to check dose and dosage schedules, drug interactions, allergies, and duplicated therapies.10,11,35,36 Embedded templates or clinical pathway order sets37 with alert systems are examples. Report of the Institute of Medicine. Report to the Congress: Selected Medicare Issues. *Provide an adequate number of nursing and pharmacy staff trained to prepare, dispense, and administer medications to children.10,11. This study highlighted the impact a pediatric pharmacist can make on prevention of ADEs and medication errors. * Confirm patient identity before administration of each dose. However, potential ADEs—those errors not causing harm—occurred in pediatric patients 3 times more often than in adults.11 In adult studies, antimicrobial agents, analgesic agents, and cardiovascular drugs are most often associated with reported errors.2,3,12 Yet for pediatrics, intravenous fluids are the most commonly cited product involved in medication errors reported to the USP.10 In pediatric and adult populations, the most commonly reported errors include the following: inappropriate medication for the condition being treated; incorrect dosage or frequency of administration of medication; wrong route of administration; failure to recognize drug-drug or drug-herbal/medicinal/dietary product interactions; lack of monitoring for drug adverse effects; “missed/late dose errors” with delayed drug administration; and inadequate communication between the physician, other members of the health care team, the parent or caregiver, and the patient.5,10 For pediatrics, incorrect dosing is the most commonly reported error, including computation errors of dosage and dosing interval.10,11,13,14 Many drugs lack formal US Food and Drug Administration licensing for pediatric indications and dosing guidelines,15 which increases the risk of these errors and accounts for the significant difference in the frequency of these errors in pediatrics (47% of errors) as compared with adults (28%).10 In teaching hospitals, prescribing errors decrease with each year of training; the error rate for attending physicians, however, is exceeded only by that of first-year residents.12 Targeted education can decrease the rates of errors, but long-term retention of information is not ensured.16 Computerized physician or prescriber order entry (CPOE), standardized order forms, and alert systems have all demonstrated success in decreasing errors.17,18 These systems can mandate attending physician cosignature for attempted overrides of the embedded templates in the system by residents.19 For example, alert systems can assist prescribers by triggering an alert when a patient on digoxin has low potassium.
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