Hospital survey shows much more needs
to be done to protect pediatric patients from medication errors
From the April 19, 2000 issue
What medication safety practices are in place when prescribing,
preparing, dispensing, and administering medications to pediatric
patients in both critical care and non-critical care units?
In our February 9, 2000, issue, ISMP and the Pediatric Pharmacy
Advocacy Group (PPAG) cooperatively distributed a survey to
newsletter subscribers to gather such information. We received
a total of 312 responses. There were 167 responses for general
pediatric units (GPU); 72 for neonatal intensive care units
(NICU); 39 for pediatric intensive care units (PICU); and
34 for Level I/II nurseries (NUR). The findings (see page
3 for table) suggest that we must do more to protect our most
vulnerable patients - children - from medication errors.
The most prevalent safety practices reported by all respondents
included entering the patient's age into the pharmacy computer
system before processing orders; providing specialized training
to nurses who work with pediatric patients; and requiring
a pharmacist to double check all pharmacy-prepared parenteral
solutions. Yet, we can't overlook that there are significant
gaps in full implementation of even the most prevalent safety
practices and variations between care settings. While 95%
of PICU respondents noted that orders always require entry
of the patient's age before processing, only 80% of GPU respondents
reported they always do this. Further, only about half of
all respondents reported that the patient's weight is always
entered into the computer before processing orders to allow
the system to warn practitioners about drug doses that exceed
safe limits. While 88-89% of PICU and NICU respondents always
require specialized training for pediatric nurses, only 66%
of GPU respondents had similar training requirements. Respondents
also noted that specialized training for pharmacy staff who
prepare pediatric parenteral solutions is dangerously inconsistent.
Two of the least prevalent safety practices included listing
the mg/kg dose as part of the drug order and having clinical
pharmacists actively participate on units. Three quarters
of all respondents told us that prescribers inconsistently
(sometimes) or never list the mg/kg dose with pediatric drug
orders. Although about two thirds of NICU and PICU respondents
reported that pharmacists always verify the mg/kg dose and
recalculate the specific patient dose before dispensing drugs,
only half reported that such safety measures are consistently
carried out for all pediatric drug orders, regardless of the
setting of care. Further, as noted below, a large proportion
of pediatric doses are obtained from floor stock, which typically
bypasses pharmacy double-check processes to verify the correct
dose. While you may expect that respondents from non-critical
care units would report less participation of clinical pharmacists,
only about two thirds of NICU and PICU respondents reported
strong clinical pharmacy involvement. Further, over a third
of NICU respondents reported the total absence of clinical
pharmacists in these high-risk patient care units!
Today, most hospitals would maintain that they have fully
implemented a unit dose drug distribution system. Yet, respondents
reported that pharmacy dispenses only 81% (mean) of pediatric
drugs in unit doses and 84% (mean) of all pediatric parenteral
solutions. With the exception of drugs with stability issues,
all pediatric IV admixture should occur in pharmacies that
provide 24 hour service. Yet, less than half of respondents
reported that essentially all parenteral solutions were dispensed
by pharmacy. While about two thirds of all respondents noted
that standard dosing/infusion rate tables are frequently or
always available for reference, 32% of NICU respondents noted
a complete absence of such guidelines. Further, only about
30% of all respondents noted that nursing calculations and
parenteral medications are independently verified by another
nurse before drug administration. Respondents also reported
that about a quarter (28% mean) of all products are obtained
from floor stock. Although NUR and NICU respondents frequently
obtain most products (75%) from floor stock, at least a quarter
of them reported obtaining < 5% of all products from floor
stock.
As may be expected, respondents from non-critical care units
(GPU, NUR) reported lower overall adherence to the safety
practices suggested in the survey than respondents from critical
care units (PICU, NICU). Yet, while children in non-critical
care units may receive potentially hazardous drug therapy
less frequently, the potential consequences of an error remain
great. For that reason, it's important to implement the same
safety practices for all pediatric drug therapy, regardless
of the patient's setting of care. PPAG and ISMP plan to publish
the complete study in an upcoming issue of the Journal of
Pediatric Pharmacy Practice.
Selected Results from ISMP-PPAG Survey of Pediatric Medication
Safety Practices
| Error Prevention Strategies |
Rating
(%) |
GPU
n=167 |
PICU
n=39 |
NICU
n=72 |
NUR
n=34 |
All
N=312 |
| Physicians include both the mg/kg dose and the calculated
dose for all drug orders. |
Always
Frequently
Sometimes
Never |
1
18
53
28 |
5
23
46
26 |
8
25
50
17 |
6
24
50
21 |
4
21
51
24 |
| Pharmacists verify the mg/kg dose listed in the prescriber's
drug orders. |
Always
Frequently
Sometimes
Never |
47
37
10
6 |
67
28
3
3 |
63
23
7
7 |
58
27
9
6 |
54
31
9
6 |
| Pharmacists recalculate the patient's actual dose before
preparing/dispensing medications. |
Always
Frequently
Sometimes
Never |
45
36
16
3 |
51
28
18
3 |
60
26
10
4 |
50
31
9
9 |
50
32
14
4 |
| The patient's weight in kg is entered into the pharmacy
computer before medication orders are entered and drugs
are dispensed. |
Always
Frequently
Sometimes
Never |
45
42
9
4 |
68
32
0
0 |
59
26
9
7 |
71
21
6
3 |
54
34
8
4 |
| The patient's age is entered into the pharmacy computer
before medication orders are entered and drugs are dispensed. |
Always
Frequently
Sometimes
Never |
80
17
2
0 |
95
5
0
0 |
87
7
0
6 |
91
6
3
0 |
85
12
2
1 |
| Pediatric and neonatal parenteral solutions that are
prepared in the pharmacy are independently double checked
by a pharmacist before dispensing. |
Always
Frequently
Sometimes
Never |
63
16
11
9 |
76
13
5
5 |
70
16
7
6 |
53
28
9
9 |
66
17
9
8 |
| Pharmacists/technicians who prepare parenteral solutions
have undergone specialized training and demonstrated competency
in pediatric drugs and dosing. |
Always
Frequently
Sometimes
Never |
51
22
12
15 |
59
31
3
8 |
67
23
1
9 |
47
28
16
9 |
55
24
9
12 |
| A clinical pharmacist is physically present on the unit
to participate in daily patient rounds and provide input
into the selection and administration of drugs. |
Always
Frequently
Sometimes
Never |
14
18
13
55 |
24
39
24
13 |
31
26
7
36 |
3
12
3
82 |
18
22
12
48 |
| Nurses who provide care to patients have undergone specialized
training and demonstrated competency. |
Always
Frequently
Sometimes
Never |
66
23
9
2 |
89
11
0
0 |
88
11
0
1 |
82
18
0
0 |
76
18
5
1 |
| Charts or tables that list infusion rates or doses for
typical parental solutions or medications are available
to minimize the need for mathematical calculations. |
Always
Frequently
Sometimes
Never |
35
35
21
9 |
38
33
21
8 |
41
28
15
15 |
39
23
6
32 |
37
32
18
13 |
| A second nurse independently double checks any dose
calculations performed in the unit before drugs or solutions
are administered. |
Always
Frequently
Sometimes
Never |
23
30
38
8 |
26
42
32
0 |
49
28
23
0 |
41
31
25
3 |
32
31
32
5 |
| Before parenteral solutions are administered, a second
nurse independently double checks the solution against
the original order and verifies, at the bedside, the line
attachment (IV, USC, etc.), rate of infusion, and the
patient. |
Always
Frequently
Sometimes
Never |
21
21
34
25 |
32
18
24
26 |
43
13
23
21 |
40
10
27
23 |
30
17
29
24 |
Key: GPU = general pediatric unit; NICU = neonatal intensive
care unit;
PICU = pediatric intensive care unit; NUR = level I/II nursery
The Institute for Safe Medication Practices
and the Pediatric Pharmacy Advocacy Group sincerely thank
all those who participated in the survey
Please use the landscape mode for your printer
in order to print the table above properly.
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