Pediatric Medication Mix-ups Targeted

Experts Tell Hospitals -- and Parents -- How to Cut the Risk of Drug Errors in Hospitalized Children

From the WebMD Archives

April 11, 2008 -- Pediatric medication errors are once again in the headlines -- and this time, the spotlight is on solutions.

The Joint Commission, a hospital accreditation group, issued new guidelines today for curbing pediatric medication errors in hospitals. The guidelines come days after the journal Pediatrics published a study showing that about 7.3% of kids at 12 U.S. children's hospitals experienced an "adverse drug event" of some sort.

That study and other events have "helped to highlight the importance of recognizing that medication safety is clearly a significant problem for children," Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission, said in a news conference today.

"There are no easy answers for improving medication safety, and the fact that we're still discussing the topic demonstrates clearly," Angood said. "We can, and we're obligated to, do better."

Preventing Hospital Pediatric Medication Errors

The new guidelines, which are partly for hospitals and partly for parents, include these tips:

  • Hospitals should weigh children in kilograms, because that's how pediatric medication doses are calculated.
  • Hospitals shouldn't give children any high-risk drugs until the child has been weighed.
  • Doctors writing prescriptions for hospitalized children should note the calculations they made to arrive at the prescribed dose. "In other words, show the math," Angood said, so that that math can be double-checked before any medications are given.
  • Parents and caregivers are encouraged to seek information and ask questions about their children's medications and to repeat instructions about those medications back to the doctor.

"Children are not just small adults," says Matthew Scanlon, MD, assistant professor of pediatrics and critical care medicine at the Medical College of Wisconsin and a member of the Joint Commission group that wrote today's guidelines. "This is another important step in increasing awareness around the unique needs of children."

Pharmacist's Practical Tips for Parents

Efforts to curb hospital medication errors aren't new, but "it's about time that there was more attention paid" to that issue in children, says Catherine Tom-Revzon, PharmD, clinical pharmacy manager at New York's Children's Hospital at Montefiore.

Continued

Tom-Revzon tells WebMD that her hospital works to minimize medication errors in various ways, including using a computer system for doctors' orders, standardizing concentrations of high-risk drugs, and putting bar codes on medications to make sure the right patients get the right medications.

She also has some simple tips for parents that can make a big difference.

  • Get an index card. On it, list all the medications your child takes regularly or as needed. Also list all of your child's doctors, allergies to medications or foods, past bad reactions to drugs, and the child's weight in kilograms (divide their weight in pounds by 2.2 to get their weight in kilograms.)
  • Make that list now -- even if your child isn't in hospital -- and keep it with you. "Just start generating that list so that if anything were to happen, you have that information handy," says Tom-Revzon, who points out that when a child is hospitalized, parents or caregivers may be too emotional or drained to make such a list on the spot.
  • Ask questions. "Be aware that there is a pharmacist who is available to talk to them about the medications, no matter which part of the hospital they're in," says Tom-Revzon. "Ask what medications the is child getting, how much, how often, and why."
  • Notice changes. If your child routinely took certain medications before getting to the hospital -- and they're not taking those drugs in the hospital -- ask about that. And if their medications in the hospital look different than what child took at home, ask about that, too. "That's how some medication errors get caught," says Tom-Revzon. "The parents are being proactive and assertive. They question, 'What are you giving my child? Why is it a different color from what I'm used to giving?'" Those differences may not be because of an error, but there's no harm in asking.
  • Be patient if you get asked several different times by several hospital workers about your child's medications. "Sometimes it ends up being the nurse, doctor, and pharmacist asking them the same questions about their medications," says Tom-Revzon. "But really, it's a safety net to ensure that we get the most accurate information."

Continued

Lastly, it wouldn't hurt to make an index card with a similar list for yourself, just in case you are ever hospitalized.

(Read one doctor's experiences with medication mistakes in WebMD's Healthy Children blog.)

WebMD Health News Reviewed by Brunilda Nazario, MD on April 11, 2008

Sources

SOURCES:

The Joint Commission Sentinel Event Alert: "Preventing Pediatric Medication Errors," April 11, 2008.

Peter Angood, MD, vice president and chief safety officer, The Joint Commission.

Matthew Scanlon, MD, assistant professor of pediatrics-critical care, Medical College of Wisconsin; member of the Joint Commission's Sentinel Event Advisory Group.

Takata, G. Pediatrics, April 2008; vol 121: pp e927-e935.

WebMD Healthy Children Blog: "Caution: The Hospital May Be Hazardous to Your Child's Health."

Catherine Tom-Revzon, PharmD, Clinical Pharmacy Manager, Children's Hospital at Montefiore.

News release, The Joint Commission.

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