August 26, 2015
As many as one in ten hospitalized children are impacted by a medication error, and up to 35% of these errors are serious or life threatening. The challenge is to learn from these events and to adopt effective strategies to prevent harmful errors from happening again. Based on the results of a recent Institute for Safe Medication Practices survey, it appears that we still have a long way to go to meet that challenge. The survey results make it clear that more needs to be done to protect pediatric patients from harmful medication errors.
The survey included five general error-prevention strategies involving all phases of the medication use process. With four of the strategies, 90% or more respondents reported implementation at least 90% of the time. Three of these strategies included using metric units of measure to: 1) express the volume of liquid medications; 2) weigh patients; and 3) document the weight on medical records and prescriptions. The fourth strategy was to standardize and limit the concentrations and dosage strengths of pediatric high-alert medications.
The fifth strategy, and the one that scored lowest in this section, involved storing adult, pediatric, and neonatal medications in separate storage locations. Only about half of the respondents reported full compliance with this strategy. Five percent of respondents said that adult, pediatric, and neonatal medications were never separated or sequestered at their practice sites, and another 5% reported employing this precaution less than 20% of the time, leaving clinicians particularly vulnerable to product selection errors.
Does your organization employ any of the above strategies for the pediatric patients in your organization?
Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.