“My child died from a medication error.”
These words from a parent whose child died at a highly respected hospital silenced the multidisciplinary panel discussing pediatric medication safety in the emergency department (ED). The conference, convened by the AAP Committee on Pediatric Emergency Medicine and Emergency Medical Services for Children, resulted in recommendations from the Academy, the American College of Emergency Physicians and the Emergency Nurses Association. The recommendations are outlined in the policy Pediatric Medication Safety in the Emergency Department, which is available at https://doi.org/10.1542/peds.2017-4066 and will be published in the March issue of Pediatrics.
Evidence shows that pediatric patients in any environment experience higher rates of medication errors than adults, and the risk of error can be amplified by the high-risk setting of the ED. As a large majority of pediatric patients cared for in emergent situations are seen in general EDs in the community setting, recommendations for safe medication delivery must apply across the spectrum of acute care settings.
Meeting the challenges
Although complex, opportunities to improve medication safety consistently involve system improvement and primarily fall into three realms: prescribing errors, ED administration errors and home administration errors.
Within the ED, computerized physician order entry (CPOE) has significantly alleviated prescribing errors, specifically those related to dose calculation. However, there is room for improvement.
Having scales that weigh children in kilograms only, with the resulting input of weight in kilograms only, will remove the common error of calculating medication dosage based on pounds. Additionally, clinical decision support built into many electronic order programs is proven to reduce prescriber error; however, alerts are commonly overridden, introducing variability in dosing.
Another challenge is the lack of universally accepted pediatric standards regarding dosing and limits, currently dictated by CPOE vendors who utilize various formularies. By developing a standard pediatric formulary with specific concentrations and standard dosing, providers can benefit from seamless education and practice patterns for prescribing high-risk and frequently used pediatric medications. Having ED pharmacists review these types of pediatric medications has had a positive effect in hospitalized pediatric patients and likely will translate to the emergency setting.
When administering medications in the acute care setting, nurses have an opportunity to verify dosing and ensure appropriate administration. In this arena, a limited number of standardized concentrations for any one medication can improve safe medication delivery, as will having premixed vials, automated dispensing cabinets and barcoded medication processes. Utilizing a two-provider check for high-alert medications and working in a distraction-free zone also will encourage safe medication administration.
The task of medication administration in the home can be daunting due to language barriers, limited health literacy and use of non-standardized delivery devices. Providing delivery devices alongside pictograms to aid in medication measurement decreases error rates, as does the AAP-supported concept of milliliter-only dosing for liquid medication.
The policy describes 18 recommendations to improve medication safety in the ED. Providers should evaluate the most high-impact, achievable recommendations to improve safe medication delivery in their environment. Recommendations include the following:
- Use a standard formulary for pediatric high-risk and commonly used medications, with a reduced number of standardized concentrations.
- Measure and record weight in kilograms only, and use length-based dosing tools when a scale is unavailable or use is not feasible.
- Implement and support the availability of pharmacists in the ED.
- Promote use of distraction-free safety zones for medication preparation.
- Create and integrate a dedicated pediatric medication safety curriculum into health care provider training programs.
- Dispense standardized delivery devices for home administration of liquid medications, and use pictogram-based dosing instruction sheets.
- Prescribe milliliter-only dosing for liquid medications used in the home.
As new processes and systems develop for medication prescribing and administration, new challenges will arise. Stakeholders should ensure that all EDs are treating pediatric patients with up-to-date processes to improve safe prescribing and administration.
Dr. Benjamin is a lead author of the joint policy and a member of the Pediatric Emergency Medicine Committee of the American College of Emergency Physicians. Dr. Frush, also a lead author, is a Chapter Affiliate member and former member of the AAP Committee on Pediatric Emergency Medicine. She directed the AAP-Emergency Medical Services for Children consensus conference on which the policy is based.