Posted: August 14th, 2022

Safety of Pediatric Medications in Emergency Departments

Safety of Pediatric Medications in Emergency Departments

Pediatric patients who receive care in emergency departments (EDs) are at high risk of medication errors due to various factors, such as the complexity of their conditions, the lack of standardized dosing and formulations, the need for weight-based calculations, the frequency of verbal orders, the interruptions and distractions in the ED environment, and the transitions of care between different providers and settings. Medication errors can lead to adverse drug events (ADEs), which are harmful and potentially preventable outcomes of drug therapy. ADEs can cause increased morbidity, mortality, length of stay, and health care costs for pediatric patients.

To improve medication safety in the ED, several strategies have been proposed by a multidisciplinary panel convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine. These strategies include:

– Using kilogram-only weight-based dosing for all pediatric medications, and avoiding the use of pounds or other units that can cause confusion and errors. Kilograms should be clearly documented and verified for each patient, and weight-based dosing should be displayed on medication labels, order sets, and infusion pumps.
– Optimizing computerized physician order entry (CPOE) by using clinical decision support (CDS) systems that can provide alerts, reminders, dosing calculators, standardized order sets, and drug information for pediatric medications. CPOE and CDS systems should be designed with pediatric-specific features and functionalities, such as age- and weight-based dosing ranges, maximum doses, appropriate dilutions and concentrations, and relevant drug interactions and contraindications.
– Developing a standard formulary for pediatric patients in the ED, while limiting the variability of medication concentrations and formulations. The formulary should include the most commonly used and high-risk medications in pediatric emergency care, and should be consistent with national guidelines and recommendations. The formulary should also specify the preferred routes, frequencies, and durations of administration for each medication.
– Using pharmacist support within EDs to assist with medication ordering, dispensing, administration, monitoring, and education. Pharmacists can provide expertise on pediatric pharmacokinetics, pharmacodynamics, dosing, compatibility, stability, and adverse effects. Pharmacists can also perform medication reconciliation, review medication orders for accuracy and appropriateness, prepare and label medications according to standard protocols, oversee automated dispensing cabinets and smart infusion pumps, verify medication administration by nurses, and counsel patients and caregivers on discharge medications.
– Enhancing training of medical professionals on pediatric pharmacology and medication safety. Physicians, nurses, and other ED staff should receive education on the principles of pediatric pharmacology, the sources and types of medication errors and ADEs in the ED, the methods to prevent and detect medication errors and ADEs, the tools and resources to support safe medication practices, and the reporting and analysis of medication errors and ADEs for quality improvement.
– Systematizing the dispensing and administration of medications within the ED by using standardized protocols, checklists, policies, and procedures. Medications should be dispensed in ready-to-use forms whenever possible, or prepared using prefilled syringes or commercially available premixed solutions. Medications should be labeled with the drug name,
concentration, dose, volume, expiration date, patient name, and barcode. Medications should be administered using appropriate devices and techniques, such as oral syringes for liquid medications or needleless connectors for intravenous medications. Medications should be scanned with barcoded medication administration systems to verify the right patient,
drug, dose, route, and time. Medications should be documented in the electronic health record immediately after administration.
– Addressing challenges for home medication administration before discharge by providing clear
and accurate instructions for patients and caregivers. Instructions should include the drug name,
strength, dose, frequency, duration,
route,
storage,
and potential side effects
of each medication.
Instructions should also include how to measure liquid medications using standard devices such as oral syringes or dosing cups,
how to apply topical medications using applicators or gloves,
and how to dispose of unused or expired medications safely.
Instructions should be written in simple language
and
at an appropriate literacy level,
and
should be provided in the preferred language
of
the patient
or
caregiver.
Instructions should be reviewed verbally
and
demonstrated visually
with
the patient
or
caregiver,
and
their understanding should be assessed using teach-back methods.

By implementing these strategies,
EDs can improve the safety
of
pediatric medications
and
reduce the risk
of
medication errors
and
ADEs.
However,
these strategies require collaboration
and
coordination among multiple stakeholders,
such as ED physicians,
nurses,
pharmacists,
administrators,
information technology specialists,
quality improvement experts,
and
patients
and
caregivers.
They also require ongoing evaluation
and
feedback to monitor their effectiveness
and
identify areas for improvement.

References:

– Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
– Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-2120.
– Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4 Pt 1):722-729.
– Ghaleb MA, Barber N, Franklin BD, Wong IC. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child. 2010;95(2):113-118.
– Kaushal R, Jaggi T, Walsh K, Fortescue EB, Bates DW. Pediatric medication errors: what do we know? What gaps remain? Ambul Pediatr. 2004;4(1):73-81.
– Stucky ER; American Academy of Pediatrics Committee on Drugs; American Academy of Pediatrics Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431-436.
– Cohen MR, Smetzer JL, Tuohy NR, et al; American Society of Health-System Pharmacists; American Academy of Pediatrics. High-alert medications: safeguarding against errors. In: Cohen MR, ed. Medication Errors. 2nd ed. Washington, DC: American Pharmacists Association; 2007:339–376.
– Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683-690.
– Rothschild JM, Churchill W, Erickson A, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010;55(6):513-521.
– Potts AL, Barr FE, Gregory DF, Wright L,
Patel NR.
Computerized physician order entry and medication errors in a pediatric critical care unit.
Pediatrics.
2004;
113(1 pt 1):
59–63
– Schondelmeyer AC,
Simmons JM,
Statile AM,
et al
Using quality improvement to reduce continuous pulse oximetry use in children with wheezing.
Pediatrics.
2015;
135(4):
e1044–e1051
– Lehmann CU,
Conner KG,
Cox JM.
Preventing provider errors: online total parenteral nutrition calculator.
Pediatrics.
2004;
113(4):
748–753

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