OAKBROOK TERRACE, Ill. – The Joint Commission, which accredits health care facilities, issued an alert on Friday to try to reduce the incidence of medication errors, which it said are three times as common with pediatric patients as with adults.
The Sentinel Event Alert noted that health care facilities frequently administer drugs made for adults to children, and there is a substantial risk that the wrong dose will be given. In addition, while adults might say something if they perceive a problem, children often cannot.
“Children often lack the communication skills to tell caregivers if something is wrong, which increases the responsibility of caregivers to carefully monitor their care to keep them safe,” said Dr. Mark R. Chassin, president of The Joint Commission. “Organizations and caregivers must commit themselves to using effective risk reduction strategies to make a difference in preventing pediatric medication errors.”
The alert said most of the harmful pediatric medication errors tracked during the past two years by U.S. Pharmacopeia involved either an improper dose or quantity. The problems often arise because hospitals and clinics have to prepare special volumes or concentrations to administer to children, because the formulas and packages are made for adults. This, in turn, requires calculations and adjustments that increase the risk for error.
To protect pediatric patients, the alert urges greater attention to precautions such as medication standardization, improved medication identification and communication techniques, as well as the use of kilograms as the standard weight measurement to calculate proper dosages.
The alert also warns providers not to dispense or administer drugs classified as high-risk until the patient has been weighed, unless it is an emergency situation, and to require prescribers to write out how they arrived at the proper dosage, as dose per weight, so that the calculation can be double-checked by a pharmacist, nurse or both.
In addition, the alert encourages providers to use pediatric-specific medication formulations and concentrations when possible, and to be “open and transparent” if an error occurs, to facilitate learning so future errors can be prevented. And it urges drug manufacturers to develop pediatric-specific formulations and to standardize labeling and packaging of all medications, and parents to be cautious, pay close attention and ask plenty of questions.
The Joint Commission issues Sentinel Event Alerts periodically as it reviews information from its Sentinel Event Database, a comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about adverse events and their underlying causes. Previous alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides.
For more information, go to www.jcipatientsafety.org.
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