Common Errors in Pediatric Drug Therapy

Prevention of errors in pediatric drug therapy begins with identification of possible sources. Reports have shown that nearly 50% of medication errors in the United States in neonatal and pediatric critical care units are attributable to prescribing and transcribing errors.2 Up to 69.5% of overall calculation errors affect pediatric patients.29

As pediatric drug therapy is based on weight, body surface area, and age, it is crucial to verify accurate weight, height, and age for dosing calculations and dispensing of prescriptions. Consistent units of measurements in reporting patient weight (kg), height (cm), and age (weeks and years) should be used. Dosing units such as mg/ kg, mcg/kg, mEq/kg, or units/kg should also be used accurately. Given the age-related differences in metabolism of additives such as propylene glycol and benzyl alcohol, careful consideration should be given to the active and inactive ingredients when selecting a formulation.

Decimal errors, including trailing zeroes (e.g., 1.0 mg misread as 10 mg) and missing leading zeroes (e.g., .5 mg misread as 5 mg) in drug dosing or body weight documentation are possible, resulting in several fold overdosing. Strength or concentration of drug should also be clearly communicated by the clinician in prescription orders. Similarly, labels that look alike may lead to drug therapy errors, e.g., mistaking a vial of heparin for insulin, when compounding parenteral solutions. Dosing errors of combination drug products can be prevented by using the right component for dose calculation (e.g., dose of sulfamethoxazole/trimethoprim is calculated based on the trimethoprim component).

The use of the "rule of six" was previously used to calculate infusions of medic-

ation such as inotropes for critically ill patients in hospitals. However, the Institute for Safe Medication Practice (ISMP) has found a relationship between medication errors and use of nonstandard injectable concentrations, such as those resulting from use of the "rule of six." The Joint Commission on Accreditation of Healthcare Organizations determined that "the rule of six" did not meet its goals of standardizing and limiting the number of drug concentrations. Use of standardized concentrations and programmable infusion pumps, such as smart pumps with built-in libraries, is encouraged to minimize errors with parenteral medications. Some hospitals have also adopted the use of enhanced photoemission spectroscopy to scan small samples of

compounded IV solution in verification of high-risk IV solutions. Introduction of technological advances such as computer physician order entry (CPOE) systems with ability for dose range checks by weight for pediatric medication orders and the use of bar code technology for dispensing of medications have decreased medication er-

32,33 rors.3A

Prevention of medication errors is a joint effort between health care professionals and parents/caregivers. Obtaining a complete medication history including over-the-counter (OTC) and complementary and alternative medicines (CAMs), simplification of medication regimen, clinician awareness for potential errors, and appropriate pa-tient/parent/caregiver education on measurement and administration of medications are essential in preventing medication errors.

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