ISMP
ISMP
Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP
ISMP
ISMP Facebook
Site Search by PicoSearch. Help

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.

Resources
Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Survey Results
Action Agendas - Free CEs
Special Error Alerts
Subscribe
Newsletter Editions
Acute Care
Community/Ambulatory
Nursing
Long Term Care
Consumer
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officer Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2014 Institute for Safe Medication Practices. All rights reserved

 
ISMP
ISMP