MEDICATION ERRORS IN CHILDREN AND PREVENT STRATEGIES
Keywords:
medication errors, pediatrics, preventionAbstract
Medication errors in children are three times as serious as those in adults. The most common error that has been frequently found is taking/giving wrong daily doses. The physiological growth of pediatrics affects treatment doses, resulting in doctors having to perform a weight-based calculation for each individual, which may lead to dose miscalculations. Other factors that contribute to medication errors among pediatrics include the use of medical formulations that are not designed for use by children; a lack of experience in diagnosing children; transcription errors by non-physicians; and pediatric medications being specified to the decimal point, making it difficult to administer exact dosages. Strategies that may decrease errors include utilizing computerized physician order entry systems and clinical decision support systems; changing prescribing behavior; preparing drug formulations specifically for children; using automated pharmaceutical machines; having clinical pharmacists within pediatric wards; using barcode systems and new technology for nursing administration; and improving communication with parents about the correct way to administer medicine. In the future, new technologies will inevitably be used to improve the safe dispensing of medicine to treat pediatric patients. Therefore, supportive policies by national healthcare organizations and hospitals are crucial.
References
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29. Mullett CJ, Evans RS, Christenson JC, Dean JM. Development and impact of a computerized pediatric antiinfective decision support program. Pediatrics. 2001;108(4):E75.
30. Lehmann CU, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator. Pediatrics. 2004;113(4):748-53.
31. 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):59-63.
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33. Sethuraman U, Kannikeswaran N, Murray KP, Zidan MA, Chamberlain JM. Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department. Acad Emerg Med. 2015;22(6):714-9.
34. Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
35. Zorc JJ, Hoffman JM, Harper MB. IT in the ED: a new section of pediatric emergency care. Pediatr Emerg Care. 2012;28(12):1399-401.
36. Chaparro JD, Classen DC, Danforth M, Stockwell DC, Longhurst CA. National trends in safety performance of electronic health record systems in children’s hospitals. J Am Med Inform Assoc. 2017;24(2):268-74.
37. Stucky ER; American Academy of Pediatrics Committee on Drugs; Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431-6.
38. Conroy S, North C, Fox T, Haines L, Planner C, Erskine P, et al. Educational interventions to reduce prescribing errors. Arch Dis Child. 2008;93(4):313-5.
39. Siebert JN, Ehrler F, Combescure C, Lacroix L, Haddad K, Sanchez O, et al. A mobile device app to reduce time to drug delivery and medication errors during simulated pediatric cardiopulmonary resuscitation: a randomized controlled trial. J Med Internet Res. 2017;19(2):e31.
40. Miller MR, Takata G, Stucky ER, Neuspiel DR; American Academy of Pediatrics Steering Committee on Quality Improvement and Management; Committee on Hospital Care. Principles of pediatric patient safety: reducing harm due to medical care. Pediatrics. 2011;127(6):1199-210.
41. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4):722-9.
42. Rosenfeld E, Kinney S, Weiner C, Newall F, Williams A, Cranswick N, et al. Interdisciplinary medication decision making by pharmacists in pediatric hospital settings: an ethnographic study. Res Social Adm Pharm. 2018;14:269-78.
43. Nunn AJ. Making medicines that children can take. Arch Dis Child. 2003;88(5):369-71.
44. Roark DC. Bar codes and drug administration: can new technology reduce the number of medication errors? Am J Nurs. 2004;104(1):63-6.
45. American Society of Health-System Pharmacists. ASHP guidelines on the safe use of automated dispensing devices. Am J Health Syst Pharm. 2010;67:483-90.
46. Schwarz HO, Brodowy BA. Implementation and evaluation of an automated dispensing system. Am J Health Syst Pharm. 1995;52:823-8.
47. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics. 1997;100(3):330-3.
48. Wong ICK, Basra N, Yeung VW, Cope J. Supply problems of unlicensed and off-label medicines after discharge. Arch Dis Child. 2006;91(8):686-8.
2. Wong IC, Wong LY, Cranswick NE. Minimising medication errors in children. Arch Dis Child. 2009;94(2):161-4.
3. Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002;11(4):340-4.
4. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20.
5. World Health Organization. Promoting safety of medicines for children. Geneva: WHO; 2006.
6. Goedecke T, Ord K, Newbould V, Brosch S, Arlett P. Medication errors: new EU good practice guide on risk minimisation and error prevention. Drug Saf. 2016;39(6):491-500.
7. Wu A. Minimizing Medication Errors in Pediatric Patients. US Pharm. 2019;44(4):20-2.
8. Ningsanon T, Chulavatnatol S, Montakantikul P, editors. Medication error prevention for patient safety. Bangkok: The Association of Hospital Pharmacy (Thailand); 2004. (In Thai)
9. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-70.
10. Pharmacy Department. Development and Data Management Division. In: Faculty of Medicine Siriraj Hospital. Annual report 2017. Bangkok: The Faculty; 2017. p.304-7. (in Thai)
11. Glanzmann C, Frey B, Meier CR, Vonbach P. Analysis of medication prescribing errors in critically ill children. Eur J Pediatr. 2015;174:1347-55.
12. Manias E, Kinney S, Cranswick N, Williams A. Medication errors in hospitalised children. J Paediatr Child Health. 2014;50:71-7.
13. Leahy IC, Lavoie M, Zurakowski D, Baier AW, Brustowicz RM. Medication errors in a pediatric anesthesia setting: incidence, etiologies, and error reduction strategies. J Clin Anesth. 2018;49:107-11.
14. Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic disease in pediatrics. Pediatrics. 1986;77(6):848-9.
15. Koren G, Haslam RH. Pediatric medication errors: predicting and preventing tenfold disasters. J Clin Pharmacol. 1994;34:1043-5.
16. Rowe C, Koren T, Koren G. Errors by paediatric residents in calculating drug doses. Arch Dis Child. 1998;79(1):56-8.
17. Glover ML, Sussmane JB. Assessing pediatrics residents' mathematical skills for prescribing medication: a need for improved training. Acad Med. 2002;77(10):1007-10.
18. Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. J Adv Nurs. 1995;22:628-37.
19. Kozer E, Scolnik D, Keays T, Shi K, Luk T, Koren G. Large Errors in the Dosing of Medications for Children. N Engl J Med. 2002;346(15):1175-6.
20. Ivanovska V, Rademaker CM, van Dijk L, Mantel-Teeuwisse AK. Pediatric drug formulations: a review of challenges and progress. Pediatrics.
2014;134(2):361-72.
21. Raksamani K. Teaching non - Technical Skills in Anesthesiology. The Thai Journal of Anesthesiology. 2015;41(1):47-52. (In Thai)
22. Grout JR. Mistake proofing: changing designs to reduce error. Qual Saf Health Care. 2006;15(suppl 1):i44-i9.
23. Johnson KB, Butta JK, Donohue PK, Glenn DJ, Holtzman NA. Discharging patients with prescriptions instead of medications: sequelae in a teaching hospital. Pediatrics. 1996;97(4):481-5.
24. Raju TN, Kecskes S, Thornton JP, Perry M, Feldman S. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2:374-6.
25. Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83(6):492-7.
26. Taylor JA, Brownstein D, Christakis DA, Blackburn S, Strandjord TP, Klein EJ, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics. 2004;114(3):729-35.
27. Stebbing C, Wong ICK, Kaushal R, Jaffe A. The role of communication in paediatric drug safety. Arch Dis Child. 2007;92(5):440-5.
28. Kahn S, Abramson EL. What is new in paediatric medication safety? Arch Dis Child. 2019;104(6):596-9.
29. Mullett CJ, Evans RS, Christenson JC, Dean JM. Development and impact of a computerized pediatric antiinfective decision support program. Pediatrics. 2001;108(4):E75.
30. Lehmann CU, Conner KG, Cox JM. Preventing provider errors: online total parenteral nutrition calculator. Pediatrics. 2004;113(4):748-53.
31. 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):59-63.
32. King WJ, Paice N, Rangrej J, Forestell GJ, Swartz R. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;112(3):506-9.
33. Sethuraman U, Kannikeswaran N, Murray KP, Zidan MA, Chamberlain JM. Prescription errors before and after introduction of electronic medication alert system in a pediatric emergency department. Acad Emerg Med. 2015;22(6):714-9.
34. Walsh KE, Kaushal R, Chessare JB. How to avoid paediatric medication errors: a user's guide to the literature. Arch Dis Child. 2005;90(7):698-702.
35. Zorc JJ, Hoffman JM, Harper MB. IT in the ED: a new section of pediatric emergency care. Pediatr Emerg Care. 2012;28(12):1399-401.
36. Chaparro JD, Classen DC, Danforth M, Stockwell DC, Longhurst CA. National trends in safety performance of electronic health record systems in children’s hospitals. J Am Med Inform Assoc. 2017;24(2):268-74.
37. Stucky ER; American Academy of Pediatrics Committee on Drugs; Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431-6.
38. Conroy S, North C, Fox T, Haines L, Planner C, Erskine P, et al. Educational interventions to reduce prescribing errors. Arch Dis Child. 2008;93(4):313-5.
39. Siebert JN, Ehrler F, Combescure C, Lacroix L, Haddad K, Sanchez O, et al. A mobile device app to reduce time to drug delivery and medication errors during simulated pediatric cardiopulmonary resuscitation: a randomized controlled trial. J Med Internet Res. 2017;19(2):e31.
40. Miller MR, Takata G, Stucky ER, Neuspiel DR; American Academy of Pediatrics Steering Committee on Quality Improvement and Management; Committee on Hospital Care. Principles of pediatric patient safety: reducing harm due to medical care. Pediatrics. 2011;127(6):1199-210.
41. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111(4):722-9.
42. Rosenfeld E, Kinney S, Weiner C, Newall F, Williams A, Cranswick N, et al. Interdisciplinary medication decision making by pharmacists in pediatric hospital settings: an ethnographic study. Res Social Adm Pharm. 2018;14:269-78.
43. Nunn AJ. Making medicines that children can take. Arch Dis Child. 2003;88(5):369-71.
44. Roark DC. Bar codes and drug administration: can new technology reduce the number of medication errors? Am J Nurs. 2004;104(1):63-6.
45. American Society of Health-System Pharmacists. ASHP guidelines on the safe use of automated dispensing devices. Am J Health Syst Pharm. 2010;67:483-90.
46. Schwarz HO, Brodowy BA. Implementation and evaluation of an automated dispensing system. Am J Health Syst Pharm. 1995;52:823-8.
47. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics. 1997;100(3):330-3.
48. Wong ICK, Basra N, Yeung VW, Cope J. Supply problems of unlicensed and off-label medicines after discharge. Arch Dis Child. 2006;91(8):686-8.
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