PEDIATRIC UPDATE

Lessons Learned: Basic EvidenceQBased Advice for Preventing Medication Errors in Children
Author: Donna Ojanen Thomas, RN, MSN Section Editors: Donna Parkman Henderson, RN, PhD, and Donna Ojanen Thomas, RN, MSN

Donna Thomas is the Director of the Emergency Department/ Rapid Treatment Unit, Primary Childrens Medical Center, Salt Lake City, UT. For correspondence, write: Donna Thomas, 2822 E. Canyon View Dr, Salt Lake City, UT 84109; E-mail: donna.thomas@ihc.com. J Emerg Nurs 2005;31:490Q3. 0099-1767/$30.00 Copyright n 2005 by the Emergency Nurses Association. doi: 10.1016/j.jen.2005.08.007

7-month-old infant with a chief complaint of vomiting is brought to the triage desk. The triage nurse does an assessment and weighs the baby. She tells the mother that the baby weighs 8 kg. The mom wants to know what that equals in pounds, so the nurse switches the scale to display pounds and tells her that the baby weighs 17.6 pounds. Theres a line of patients at triage, so the nurse hurriedly documents the weight on the triage note. The chart has a space for weight in kilograms and, distracted, she writes in 17.6, failing to recognize that she did not switch the babys weight back to kilograms. The baby is taken to a room and assessed. A fluid bolus of 20 mL/kg (352 mL) is ordered, based on the weight documented on the chart. The nurse gives the baby a bolus of 352 mL, more than twice what the baby should have received. The error is not detected until the admitting physician writes an order for an intravenous (IV) antibiotic. The nurse thought the amount of medication seemed high, checked the weight on the chart, and reweighed the baby. Luckily, the baby had no preexisting conditions such as cardiac, lung, or kidney disorders and was able to handle the excess fluid without problems. If the nurse had not noticed the inaccurate weight before giving medication, the outcome could have been much worse. This specific actual case is not an isolated phenomenon. In fact, it is far from isolated. Preventing medical errors is currently the focus of many organizations, including the Emergency Nurses Association and the Joint Commission of accreditation of Healthcare Organizations, especially since the Institute of Medicine report in 1998 described medical errors as the eighth leading cause of death.1 Of all medical errors,

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medication errors have been studied the most because they are the second most frequent and the second most expensive event causing liability claims.2 In infants and children with fewer reserves, these errors can have serious consequences. Most studies on medication errors in children are performed in inpatient units. One such study looked at preventable adverse drug events in pediatric inpatients and found that, although the preventable mistake rate was similar to that of a previous adult study, the potential rate of mistakes was 3 times higher, especially in neonates in the intensive care unit.3 This study also revealed that obtaining an incorrect weight or recording the weight incorrectly, such as in the case of the actual experience described above, caused 10% of all errors. The incidents of medication errors in the pediatric emergency department (ED) are not fully described and this author could find no articles on the prevalence of medication errors in children seen in the adult setting. One study of pediatric ED patients showed that about 10% of patients may be exposed to medication errors.4 Most of the medication errors occurred during the evening or night shifts, and on weekends. Trainees were more likely to make errors, and seriously ill patients were more at risk.4 During a 5-year study of over 250,000 patient visits in a pediatric ED, there were only 33 incident reports filed involving medication or fluid errors, even though more were discovered in chart reviews.5 Actual incidents may be underreported because current mechanisms for reporting errors are often viewed as punitive. Why are medication errors more likely in a pediatric ED patient? Dosages need to be calculated on a milligram per kilogram dosage. Weight-based dosing is often complicated and calculations can be performed incorrectly. In a busy ED, medications are often given quickly and fewer people are involved. Often the rule about double-checking doses is difficult to adhere to when a medication must be given immediately, especially in critical patients. Many medications are supplied to the pharmacy and to the ED in standard dosages that must be diluted for children. Moreover, some common medications that are given frequently in the ED may come in many different strengths. Acetaminophen, for example, may be available in as many as 9 different liquid concentrations, sobering given the potential for serious sequelae with overdoses of acetaminophen. In 1 study, acetaminophen was the most

common drug involved in errors, followed by antibiotics and asthma medication.4 Other factors involved in medication errors in children have been identified.6 They include: . Residents and trainees: Errors in dosing are more likely to be made by residents and other trainees. . The nursing shortage: The nursing shortage may result in fewer and less experienced nurses who may not be familiar with pediatric medications. . Overcrowding in the ED: This may result in having to board inpatients for extended periods of time in addition to caring for other ED patients. . Stress: Often nurses have several patients to care for and are interrupted, which limits their ability to focus. . Lack of time to document: If the nurse doesnt have time to document an order, another nurse, in an attempt to help, may repeat the medication. Or if medications are not documented on the record or in report when the patient is admitted, the dose may be repeated on the inpatient unit. . Verbal orders and language barriers: Verbal orders may result in wrong doses being given. Discharge instructions may be a problem if the parents do not speak English. . No pharmacist assigned to the ED: Many EDs do not have a pharmacist to assist with medication preparation and to serve as a resource. How can nurses caring for children in the ED minimize the risk of a medication error? Here are several suggestions. Weigh all patients in kilograms. To prevent the error described in the example above, we modified our scale to weigh only in kilograms. If a parent wants to know the weight in pounds we have a conversion chart to use. Dont use a reported weight. Often parents will say, We were just at the doctors office and he weighed 18 pounds. Insist on reweighing in kilograms rather than converting the weight the parent has given to kilograms. Look at the weight when you are preparing a bolus or a medication, then look at the child. If you have any doubt about the documented weight, it only takes a moment to reweigh the child. Weighing the child correctly in kilograms would prevent many errors in calculating doses of medications and IV fluids.

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Obtain a good history. Generally, children are not taking as many medications as adults, but make sure you ask about all drugs, including over the counter drugs, just as you do in adults. Check for allergies and make sure you use an allergy band or some method to highlight the allergy on the chart.

We modified our scale to weigh only in kilograms

If a parent questions a dosage, double-check it. Children cannot question you, but their parents know their children better than anyone else, especially parents of children with chronic conditions. Be particularly careful if a patient comes in with any kind of an IV infusion line. Know what you can, and cannot, infuse through the line. Double-check all medications dosages with another nurse. Ninety-five percent of all mistakes are found when someone checks the work of others.7 When checking another nurses calculations, dont just look them overdo the calculations yourself. Double-check both the strength being given and the dosage, and of course, make sure you have the right patient. Its easy to mix up orders in the ED. Be especially aware of high-alert medications. The Institute for Safe Medication Practices (ISMP) defines these as drugs that bear a heightened risk of causing significant patient harm when they are used in error.8 This list includes adrenergic agents such as epinephrine, sedation drugs including moderate oral sedation agents for children such as chloral hydrate, IV and oral narcotics, insulin, and heparin. Additional information on medication safety can be found on the ISMP website http://www.ismp.org. Label all medications that are drawn up. Even if you are administering a medication right away, label it. You could get distracted and set it down for a moment and someone else could mistake it for something else. Errors have been made when IV infusions have been flushed with medication that was mistaken for normal saline. Our hospital buys syringes that are prefilled and labeled as a normal saline flush to prevent nurses from flushing IVs with other medications or drawing up the wrong fluid to be used as flush. Label everything and include the strength and dose on the label. Use infusion pumps to administer all IV medications and fluids to children. Infusion pumps can control the amount

of fluids that are infused and prevent fluid overload. Consider the use of smart pump technology. These IV pumps incorporate computer technologies for storing drug information, making calculations, and checking entered information against dosing parameters. Our hospital has adapted this method, along with standard drug concentrations and, as a result, has reduced by a full 73% the number of reported errors associated with continuous medication infusions given in the pediatric intensive care unit and the neonatal intensive care unit.9

Our hospital buys syringes that are prefilled and labeled as a normal saline flush, to prevent nurses from flushing IVs with other medications or drawing up the wrong fluid to be used as flush. Label everything and include the strength and dose on the label.
Document medications in a timely manner on the ED record. We have had incidents in which a drug was given twice because the nurse had not charted the drug after she gave it. The physician, thinking the drug was not given, then asked another nurse to do it. The second nurse checked the chart and saw that it was not documented (ie, not given), so gave the child another dose. She did not check with the patients nurse first, which would have been another way to prevent this error. Make incident reporting nonpunitive. At our hospital, we call our incident reports event reports. The staff is encouraged to fill out these reports and they are first reviewed with the charge nurse. The nurse manager reviews the report with the nurse involved to determine if more education is needed. By reviewing our reports, we notice trends. When the same error is being made, we can educate the staff and change our systems to prevent it. Event reports led us to change our scales to measure weight only in kilograms. Study your pediatric population to see what your medical errors are, and review them with staff, but dont make it punitive. Look for trends in the type of errors; look for ways to improve the system, not punish the person making the error. It is rare that a nurse intentionally does the wrong thing and rare, in our experience,

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that the error cant be addressed by making the entire system safer. Check out your medication room. Look for potential sources of errors. Do you have drugs that have similar labels that should not be stored together? Can you get smaller volumes or concentrations of drugs to use for pediatric patients? Does your staff have access to pediatric drug references that allow you to quickly double-check a prescribed dosage? Our hospital has a standard drug reference to be used to double-check dosages and side effects. Use oral syringes to administer oral medications, never use a luer-lock syringe to draw up oral medications these can also be mistakenly injected into an IV site.

6. Selbst S, Levine S, Mull C, Bradford K, Friedman M. Preventing medical errors in pediatric emergency medicine. Pediatr Emerg Care 2004;20:702-9. 7. Campbell G, Facchinett N. Using process control charts to monitor dispensing and checking errors. Am J Health Syst Pharm 2000;55:946-52. 8. Institute for Safe Medication practice. Available at: http://www. ismp.org/tool/highalertmedications.pdf. Accessed July 26, 2005. 9. Larsen G, Parker B, Cash J, OConnell M, Grant M. Standard drug concentrations and smart pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics 2005;116:e21-e5. Available at: http://pediatrics.aapublications. org/cgl/content/abstract/116/e21. Accessed July 26, 2005.

Look for trends in the type of errors; look for ways to improve the system, not punish the person making the error.
Provide resources and education. Because of the nursing shortage, we hire some nurses with less experience now, and have noted that many medication errors occur with newer staff. We are working to provide more training and support in giving medications, especially sedation drugs. The potential for medication errors exists in both the pediatric and the adult ED, but many medication errors with pediatric patients can be prevented by simply using a scale that weighs only in kilograms and double-checking drug calculations with another ED nurse. Children can be more vulnerable than adults and depend on us to first do no harm.
REFERENCES
1. Kohn L, Corrigan J, Donaldson M, eds. To err is human Building a safer health system. Washington, DC: Institute of Medicine; National Academy Press; 1988. 2. Physician Insurers Association of America. Medication Error Study. Washington DC: Physician Insurers Association of America; 1993. 3. Kaushal R, Bates D, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001: 2114-20. 4. Kozer E, Scolnik D, Macpherson A, et al. Variables associated with medication errors in pediatric emergency medicine. Pediatrics 2002;110:737-42. 5. Selbst S, Fein J, Osterhoudt K, Ho W. Medication errors in a pediatric emergency department. Pediatr Emerg Care 1999; 2000:15:124.

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