Pediatric Weight Errors and Resultant Medication Dosing Errors in the Emergency Department

A retrospective study of 79,000 ED encounters at a children’s hospital and two general hospitals. The intent of the study was to characterize the frequency of weight errors and to determine of the children’s hospital was any better at correcting errors than the general hospitals. The findings were that weight errors were uncommon (0.63% of all weights, as defined by the weight being a new extreme value on the growth chart) in the 3 EDs, but they led to identifiable weight-based medication-dosing errors with the potential to cause harm. The rates of error where similar across hospitals, and it looked like the children’s hospital was slightly better at intercepting errors once they were committed. Common weight errors included the weight in pounds being substituted for the weight in kilograms and decimal placement errors.

Hirata 2017 (Link) | PubMed 28976456 | Author Search

Tenfold Medication Errors: 5 Years’ Experience at a University-Affiliated Pediatric Hospital

A study of pediatric inpatient safety reports. From the abstract: “From 6643 medication-related safety reports, 252 10-fold medication errors were identified at a mean reporting rate of 0.062 per 100 total patient days. Morphine was the most frequently reported medication, and opioids were the most frequently reported drug class. Twenty-two reports described patient harm. Intravenous formulations, paper ordering, and drug-delivery pumps were frequent error enablers. Errors of dose calculation, documentation of decimal points, and confusion with zeroes were frequent contributing causes to 10-fold medication error.”

Doherty 2012 (Pediatrics) | PubMed 22473367 | Author Search

Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics

Prehosp Emerg Care. 2017;21:185-191.

This survey of paramedics found that pediatric dosing errors in the prehospital period are common. Respondents used varied methods for estimating weight of pediatric patients in order to calculate drug doses, and they advocated for pediatric training and standardized weight estimation methods to reduce risks. These findings suggest several possible interventions to enhance pediatric medication safety in the prehospital setting.

| PubMed 28257249 | Author Search

New Technologies as a Strategy to Decrease Medication Errors: How Do they Affect Adults and Children Differently?

A review of techniques used to reduce medication errors in pediatrics. Within the limitations of the heterogeneous system that makes up information technology for child health, the authors conclude that CPOE and accompanying decision support can help but also creates new types of error (World Journal of Pediatrics).

Ruano 2015 (Link) | PubMed 26684316 | Author Search

Optimization of Drug-drug Interaction Alert Rules in a Pediatric Hospital’s Electronic Health Record System Using a Visual Analytics Dashboard

Describes an effort to reduce alert rates from drug-drug interactions, with some evidence that fewer alerts led to increased salience (lower override rates). Rates for pharmacists fell from 58.74 alerts per 100 orders to 25/100 orders. For providers, the drop in rates was less dramatic (~20 to 15/100 orders) but they were getting far fewer alerts in the first place. Pharmacists’ rate of alert overrides fell, but providers’ rates stayed the same. The basic methodology used was a visualization tool developed in a commercially available data-visualization application.

Simpao 2015 (JAMIA) | PubMed 25318641 | Author Search

Frequency and Severity of Parenteral Nutrition Medication Errors at a Large Children’s Hospital After Implementation of Electronic Ordering and Compounding

Comparison of reported error rates to error rates after implementation of a new pediatric total parenteral nutrition system at a tertiary children’s hospital. Authors found a much lower rate of error in their system (230 errors/84,503 prescriptions, almost all at the administration step) as compared with reported literature.

MacKay 2015 (Link) | PubMed 26214511 | Author Search