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
Chart review of 33 medication and fluid errors identified in a pediatric emergency department through incident reports filed over a 5-year period showed the most common error was an incorrect dose of medication (35%). Incorrect recording of patient weights commonly led to an incorrect medication dose.Selbst 1999 (Link) | PubMed 10069301 | Author Search
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
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
A focus-group study from the International Journal of Pharmacy Practice from Birmingham Children’s Hospital (UK) found that prescribers perceived a lack of needed prescribing information–especially dosing information–in current technology resources.Burridge 2015 (Link) | PubMed 25363357 | Author Search
International Journal of Medical Informatics
A retrospective analysis of inpatient medication orders and dosing alerts at a large, academic, pediatric medical center. Pediatric orders had higher odds for an alert compared to adult orders. The alert rate was highest for immunosuppressive agents (> 50% alert rate), medications for neonates (6.7%), orders for rectal administration (9.5%), and orders for continuous infusion (7.9%). Orders for albuterol continuous aerosol and heparin injection solution had near-100% alert rates. Opioid alerts had among the lowest alert rates, at 7.4%. There was also a temporal analysis that indicated that January wasStultz 2015 (Link) | PubMed 25466381 | Author Search
This before-and-after study found that introduction of a tiered alert system for medication dosages in pediatric patients led to an increase in alerts, but also resulted in fewer overridden alerts and more medication order revisions. This work emphasizes the need to improve electronic medication alerts to make them more actionable and reduce alert fatigue. (Journal of Patient Safety)Balasuriya 2014 (Link) | PubMed 25370855 | Author Search
Robinson CA, Siu A, Meyers R, Lee BH, Cash J
J Pediatr Pharmacol Ther 2014 Apr;19(2):118-26
OBJECTIVES: To establish standardized, rounded doses of medications for neonates in the neonatal intensive care unit (NICU) through a multi-institutional peer-reviewed process.
METHODS: Pediatric faculty and pediatric pharmacy residents from the Ernest Mario School of Pharmacy (Piscataway, NJ) conducted a systematic review of rounded, weight-based medication information for neonatal patients from September 2010 to April 2011.