Assessing Medication Safety in Settings Not Designated Solely for Pediatric Patients
Problem: Infants and children can arrive at any emergency department (ED) or healthcare facility seeking medical treatment, but some organizations (e.g., community hospitals, critical access hospitals) might not be properly equipped for the array of pediatric conditions that present. In an article published about Stanford Hospital’s new ED, the pediatric emergency medicine director, Bernard Dannenberg stated, “All the large academic medical centers in the United States have free-standing pediatric emergency departments, because children are a special patient population that you shouldn’t be mixing with adults. Adults have different illnesses…children need to be in an environment that not only looks physically different, but they have to be managed by a team that just deals with children.” Providing this specialized care outside of children’s hospitals and large academic medical centers can be challenging.
As of 2019, there were 5,591 EDs but only 250 children’s hospitals in the United States.1,2 The 2015 Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project found that pediatric visits represented approximately 20% of all ED visits, with infants and children less than 5 years old accounting for more than 40% of all pediatric ED visits.3 In addition, a national survey that was conducted to assess the availability of pediatric services in US EDs reported that in EDs that see both adults and children, only 10% had a separate pediatric ED. The 2013 study noted that only 17% of EDs had a designated physician or nurse coordinator for pediatric emergency care.4
Healthcare practitioners may not have the opportunity to take care of pediatric patients during their onboarding, yet could be “signed-off” to treat all patients without completing a pediatric-specific competency assessment. In addition, community hospitals experience seasonal fluctuations in the number of pediatric admissions or visits, with the volume declining during warmer months and peaking in the winter. In some organizations with variations in pediatric encounters, practitioners end up having mixed assignments (pediatric and adult patients) throughout the year, and the organization may struggle to maintain a core pediatric staff who are readily available in key locations (e.g., ED, inpatient, procedural areas).
The 2022 ISMP article, Survey results from pharmacists provide support to enhance the organizational response to codes, revealed that many of the respondents felt ill-prepared to participate in pediatric codes. Nearly one-third (32%) were concerned that they might dispense and/or administer an incorrect medication or dose. Of the pharmacists who work in hospitals that serve adult and pediatric patients, less than half (44%) had received training about pediatric doses and less than one-third (31%) were required to be certified in pediatric advanced life support (PALS).
A small community hospital reported to us that it transfers all pediatric patients who arrive in their ED to a nearby children’s hospital. But, to stabilize the pediatric patient for transfer, they often need to consult with the children’s hospital, especially to administer certain medications such as vasopressors. The community hospital does not have access to syringe pumps and creates custom infusion concentrations that can be administered using their large volume parenteral (LVP) pumps. Practitioners worry they will make an error when calculating weight-based doses or might prepare an incorrect volume or concentration of a pediatric medication or solution. The simple misplacement of a decimal point can result in a 10-fold medication error, which could have devastating consequences for pediatric patients.
Given that pediatric patients are a unique and clinically diverse population, community hospitals, critical access hospitals, and other traditional adult-based settings should be equipped to manage these vulnerable patients. If your organization lacks pediatric-sized equipment, policies and procedures to ensure timely transfer of care, lacks standard pediatric concentrations/order sets and has limited awareness of pediatric guidelines/dosing references, or inadequately prepared staff,5,6 these can be barriers to providing optimal emergency care for children.
Safe Practice Recommendations: Since pediatric patients often need to be treated in healthcare settings that are not designated solely for children, organizations should complete a gap analysis around current pediatric care and consider the following recommendations to safeguard against harm in this patient population.
Appoint pediatric coordinators. The American Academy of Pediatrics policy statement, Pediatric Readiness in the Emergency Department, recommends that a physician coordinator should be identified by the ED medical director, or a registered nurse coordinator identified by the ED nurse director, should serve as a designated pediatric emergency care coordinator (PECC). EDs should also proactively involve a pharmacist with pediatric competency to oversee critical safeguards built into systems and processes (e.g., pediatric dosing guidelines and order sets). These individuals should possess pediatric expertise and be responsible for addressing pediatric standards, implementing pediatric policies and procedures, preparing staff, and ensuring the availability of appropriate pediatric medications, supplies, and equipment (e.g., syringe pumps, oral liquid medication measuring devices).
Designate space. Determine if your ED, inpatient, and procedural areas can be structured in a way that separates pediatric patients from adult patients and can be staffed with competent practitioners depending on the pediatric census. Differentiating the environment where pediatric patients are treated can help orient practitioners to readjust their mindset for the population they are treating.
Create pediatric protocols and guidance. Collaborate with pediatric institutions and emergency medical services (EMS) agencies to adopt pediatric pathways, guidelines, algorithms, and checklists (e.g., confirm weight-based doses). Develop transfer protocols and partnerships with academic inpatient pediatric institutions for patients requiring specialized care.
Leverage the EHR. Evaluate how pediatric patients are differentiated from adults in the electronic health record (EHR). Some organizations have implemented a banner or alert to notify practitioners they are viewing a pediatric patient’s medical record. If your hospital primarily treats adult patients, and only sees a few pediatric emergencies per year, it is critical to prebuild common pediatric medications and critical infusions (e.g., EPINEPHrine, DOPamine) in your computer systems. Implement clinical decision support (e.g., order sets, dose range checking) with pediatric-specific, weight-based (e.g., mg/kg) doses in your EHR, and link orders to the patient’s age or weight. Check if your EHR can incorporate age-based percentile support which could help raise suspicion that a weight or height may be incorrect.
Standardize pediatric concentrations. Provide pediatric medication infusions in standard concentrations. When choosing standard concentrations, use the American Society of Health-System Pharmacists (ASHP) Standardize 4 Safety standard concentrations for pediatric patients as a reference. When possible, use commercially available, ready-to-administer syringes and premixed infusions.
Implement a pediatric code cart. Maintain a separate pediatric code cart, distinct from the adult code cart, that is clearly labeled for pediatric use and has pediatric equipment, supplies, medications, and formulations. Provide these in all locations where pediatric patients may be cared for, and ensure staff know where they are. Store medications in a standard configuration, with labels facing up, separating look-alike products. In the code cart, provide preprinted labels that specify the medication name, strength, and volume to assist in labeling practitioner-prepared medications and infusions in a standard concentration. Routinely review medications ordered during pediatric codes to ensure the drugs and doses used are evidence-based and readily accessible in the code cart.
Provide pediatric drug resources. Provide metric scales (e.g., infant, stretcher) in all areas where patients are admitted or encountered. Ensure that all pediatric code carts include emergency medication references specific to pediatric weight ranges based on the organization’s standard concentration(s). Consider using a well-vetted, commercially available software system or phone application for drug information such as dosing, preparation instructions, and monitoring; alternatively, develop organization-specific weight-based emergency medication tables that are immediately available on all pediatric code carts. Stock the most recent version of the Broselow Pediatric Emergency Tape on code carts and use it as a tool for determining the correct medication dose, based on the child’s length, when the patient’s weight is unknown, and they require emergency stabilization.
Educate staff. Healthcare educators should develop pediatric competency assessments for key staff (e.g., prescribers, nurses, pharmacists, pharmacy technicians) to complete during orientation and at least annually thereafter. Consider requiring current PALS certification for practitioners working in areas that see pediatric patients. Ensure staff are aware of and have easy access to pediatric protocols and guidance.
Use simulation. Conduct regularly scheduled interdisciplinary code simulations focusing on treating pediatric patients (e.g., entering pediatric weight-based orders in the EHR, calculating doses, compounding pediatric infusions, programming a pediatric infusion on a smart pump, responding to a pediatric code). Conduct post-simulation debriefings with participants so they can ask questions, share concerns, and review what went well and what could be improved to better approach pediatric-specific situations. For additional information, see our May 4, 2023 feature article, The role of simulation when onboarding healthcare professionals—Part II.
Educate patients and caregivers. Parents serve as important advocates for their children and can help prevent errors, but in some cases may unknowingly contribute to errors as well. Be sure to review our June 16, 2011 feature article, Parents can detect, contribute to, or be affected by critical events during a child’s hospitalization. Encourage parents to report any concerns or worries regarding their child’s care and tell them to continue asking questions or voice concerns until they receive an answer that they are comfortable with and fully understand. At the same time, parents need to know what NOT to do. Educating parents and orienting them to the care setting can help avoid common issues like touching or even accidentally disconnecting tubes or drains.
Report errors. Encourage staff to share hazardous conditions, close calls, and actual errors that have occurred when treating pediatric patients both internally and externally. Create action plans and share the steps that the organization has taken to prevent incidents from happening again. If having to care for pediatric patients is uncommon, consider conducting retrospective case reviews to discuss what went well and what could be improved upon.
Measure performance improvement. When determining organization-wide quality improvement measures, remember to include pediatric-specific indicators (e.g., pediatric order set/drug library compliance rate, percentage of ED staff with PALS certification).
Seek expertise. Reach out to colleagues who work in children’s hospitals to discuss pediatric medication safety challenges and how to best approach them. Establish routine check-ins with these colleagues to stay up to date on trends in pediatric medicine and continually assess pediatric readiness. Also, refer to resources on the Pediatric Pharmacy Association website, and pediatric topics posted on the Medication Safety Officers Society website.
Consult resources. Review the following resources and use the additional tools/assessments provided.
National Pediatric Readiness Project (NPRP), which provides a readiness checklist and toolkit for download. This project developed a weighted pediatric readiness score (WPRS) based on a web-based assessment of ED readiness for children as measured by adherence to the above guidelines. For example, the study reported only two-thirds (67%) of respondents weighed children in kilograms only. Since pediatric doses are based on the patient’s weight (e.g., mg/kg), this is a crucial part of the medication-use process.
The ISMP Targeted Medication Safety Best Practices for Hospitals, Best Practice #3, which calls for organizations to measure and document patient weights in metric units only. Significant medication errors have occurred when the patient’s weight was communicated and/or documented in nonmetric units of measure (pounds and ounces) and was confused with kilograms or grams.
Pediatric Readiness Recognition Program, which designates and verifies a hospital’s ED capacity to provide care to children, and includes medical recognition programs developed by some states. Of the 17 states that took part in a 2021 NPRP assessment, they found that EDs that participated in an ED readiness recognition program scored 24 points higher (on a scale of 0 to 100) on their WPRS than EDs that did not participate in the program.
Treating adults in pediatric settings. While this article focused on pediatric patients in healthcare settings not designated solely for children, some of the challenges and recommendations are applicable when treating adults in pediatric settings. Adults can also seek medical treatment at any ED or healthcare facility, including children’s hospitals. In fact, during the coronavirus disease 2019 (COVID-19) pandemic, to meet the needs with the surge of adult patients, pediatric intensive care units were repurposed for adult critical care. However, pediatric-trained practitioners are not always prepared to care for adult patients. One challenge is that pediatric providers are so used to weight-based dosing that they may not take maximum doses into consideration when treating adults, which could lead to an overdose of medication especially in obese patients. In pediatric hospitals that treat adults, processes and systems (e.g., EHR clinical decision support, smart pumps) should be evaluated to support adult medication treatment and doses. For practitioners working in pediatric settings that occasionally see adult patients, require completion of competency assessments for common adult emergencies and disease states (e.g., heart disease, stroke) during orientation and annually. Also, consider requiring current basic life support (BLS) and advanced cardiovascular life support (ACLS) certification.
- Emergency Medicine Network. 2019 national emergency department inventory—USA. Accessed April 7, 2023.
- Casimir G. Why children's hospitals are unique and so essential. Front Pediatr. 2019;7:305.
- McDermott KW, Stocks C, Freeman WJ. Overview of pediatric emergency department visits, 2015. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality. August 2018. Accessed April 7, 2023.
- Sullivan AF, Rudders SA, Gonsalves AL, Steptoe AP, Espinola JA, Camargo CA Jr. National survey of pediatric services available in US emergency departments. Int J Emerg Med. 2013;6(1):13.
- Remick K, Gausche-Hill M, Joseph MM, et al. Pediatric readiness in the emergency department. Ann Emerg Med. 2018;72(6):e123-36.
- Ray KN, Olson LM, Edgerton EA, et al. Access to high pediatric-readiness emergency care in the United States. J Pediatr. 2018;194:225-32.e1.
Institute for Safe Medication Practices (ISMP). Assessing medication safety in settings not designated solely for pediatric patients. ISMP Medication Safety Alert! Acute Care. 2023;28(12):1-5.