Sick Children Face A Potentially Deadly Danger: Medication Errors

Sick Children Face A Potentially Deadly Danger: Medication Errors

Pediatric patients are vulnerable to mistakes made in how much medicine to give and when to give it

One of the biggest dangers sick children face—whether they are at home or in the hospital—involves the very thing that is supposed to help them get better: medication.

Jamie Harris says she thought a lot about medication errors as a nurse in the neonatal intensive-care unit at Boston Children’s Hospital. Many of her young patients were on potent drugs, she says, and once they were discharged from the hospital, it was up to their parents to deliver the proper dose.

When to give the medicine, how much to give and what tool to use to deliver it were questions that could easily trip up caregivers, she says. Depending on the medication, an overdose could be lethal.

So Ms. Harris came up with a low-tech fix: Give parents a special kit for storing the medications, instructions and dosage tools. Most important, the kit comes with a bright red warning sign that reads: “Distraction Free Zone”—a signpost meant to keep parents alert and on-task.

“In a health-care environment, where technology is talked about so much, sometimes it really is about going back to the bedside and sitting with the family and doing education on basic concepts,” says Ms. Harris, now a nurse practitioner at Boston Children’s.

Dosing dangers

Ms. Harris’s idea is one of many being implemented around the country to protect pediatric patients from medication mistakes, an all-too-common occurrence that poses a significant danger to children because of their small body size.

Getting a handle on the scope of the problem has proved challenging, in part because the way researchers measure errors varies. But researchers from Johns Hopkins University estimated in a 2007 review paper that anywhere from 5% to 27% of medication orders for children involve errors. The mistakes can occur anywhere along the path from when a clinician writes a prescription to when the pharmacist fills the order or a parent or professional administers the drug.

Another study, by researchers at Nationwide Children’s Hospital and published in the journal Pediatrics in 2014, estimated that out-of-hospital medication errors affect a child every eight minutes, on average.

Part of the problem, health professionals say, is that dosing is often based on a child’s weight, which can lead to calculation errors. Some liquid medications only come in concentrations suitable for adults, so the pharmacist may have to dilute it for a child. And a parent measuring a dose may use a spoon or something else on hand, instead of a specialized tool to pull the correct amount.

Even the most conventional drugs can pose problems.

Something as simple as over-the-counter ibuprofen needs to be delivered with caution, says Jamie Irizarry, medication safety nurse at the Children’s Hospital of Philadelphia. The liquid version of the painkiller is commercially sold in at least two concentrations, and parents can inadvertently buy the wrong one without ever knowing they had another option.

“This scenario plays out with dozens of patients a day,” Ms. Irizarry says. “You may not be giving them enough medication to reduce their pain. The opposite is you could give them more or overdose them.”

Many solutions

These days hospitals are trying everything from computerized alarm systems to new parental education tools to prevent medication errors.

A 2015 review of 63 research papers on reducing pediatric medication errors found that 95% of the innovations studied showed positive results. That suggests there may not be a single “right” intervention, and that institutions may want to identify their own specific weak spots and find ways to tackle them.

“Everybody measures things a little differently,” says Michael Rinke, medical director of pediatric quality at the Children’s Hospital at Montefiore in New York and an author on the 2007 and 2015 review papers. “It’s really hard to understand what a large institution or even a small institution should prioritize.”

Clinicians, meanwhile, are forging ahead with innovative efforts to end mistakes.

In July, Ms. Irizarry was part of a team that created a safety sheet for parents highlighting the differences between the different versions of ibuprofen. “When they have the actual bottle of ibuprofen in their hands, they can look at the sheet and make sure that they’ve administered the correct dose of the correct concentration,” she says.

Shonna Yin, an assistant professor of pediatrics and population health at NYU Langone Medical Center, is developing a computer program that automatically generates instruction pictograms when prescribers enter a medication into a child’s electronic medical record.

A few years ago, Dr. Yin tested whether cartoonlike diagrams with plain-language instructions—instead of the more traditional, sometimes esoteric written ones—might improve dosing accuracy. She found that parents who were given the pictures were more knowledgeable overall about how often to administer medication compared with a control group that received only written instructions. They also were more likely to give the correct number of total doses prescribed and less likely to give inaccurate doses. The study was published in the Archives of Pediatric & Adolescent Medicine in 2008.

“We’re planning to do this for five of the most common languages” in New York City, and eventually many more, she says of the computer program she is creating.

Safety nets

In hospitals, meanwhile, improvements have been made in devices like infusion pumps to protect children who receive medications intravenously.

Nurses or clinicians typically are required to program the pumps to automatically drip a medicine at a particular rate—but even one misplaced number or decimal point can result in the patient getting 10 or even 100 times as much as the doctor intended.

Some pumps now allow physicians to wirelessly send medication orders straight to the device, cutting out the middleman. Others have built-in alarms to help detect and prevent potential mistakes

“It would either warn me, ‘Do you really want to do this?’ or, in fact, stop me” from giving the medication, says Michelle Mandrack, who was an acute-care nurse for two decades and now consults for the Philadelphia-based nonprofit Institute for Safe Medication Practices.

These improvements provide a “safety net for the nurse,” says pharmacist Thanhhao Ngo, clinical coordinator of the pharmacy department at Dell Children’s Medical Center of Central Texas.

“When you think about all of the things that compete for a nurse’s attention,” she says, “anything you can do to take away any additional stress is always a good thing.”

Reprinted from the Wall Street Journal.