The Problem
Medication errors that happen to children can have disastrous consequences for the child and his or her family. Unfortunately, external factors increase the risk for pediatric medication errors. Most medications are designed for adults not children. In addition, with so few alternatives, adult medication dosages must be modified for pediatric administration. Modification requires several steps that include the accurate weight of the child and converting the adult medication concentration into an appropriate pediatric dosage.
The Institute of Medicine’s (IOM) Emergency Care for Children found that little data has been collected concerning emergency departments and emergency medical service agencies.1 However, available data reveals that medication errors occur frequently in the emergency medical system. 1[i], [ii], [iii], [iv] In addition children treated for emergency ailments are more vulnerable to medication prescribing errors then children with nonemergency illness or injuries.1 [v]
The emergency setting is uniquely prone to pediatric medication errors. Patient weight is frequently based on approximation, and medication conversion requires math skills and appropriate placement of decimal points. Emergent situations often allow little time for double checking medication dosages.
History
Medication errors have been embedded in healthcare for many years. Nearly 50 years ago, for example, an error in medication administration occurred that claimed the lives of two premature babies, according to a 1959 newspaper headline in the Independent Press-Telegram.2 Four other infants who had received the same medication in their milk survived due to the prompt action by hospital staff once the mistake was discovered.
Incorrect decimal placement from 10-100 times the dose ordered, has been cited as a contributing factor for medication errors in IOM’s Preventing Medical Errors published in 2007.3 When converting the concentration of adult medications to an appropriate strength for children, miscalculations due to weight estimations and/or incorrect decimal point placement will lead to over or under dosing the medication for pediatric patients. In some cases children have received the entire adult strength of some medications exceeding the recommended dosage by up to 1,000 times the amount prescribed.
A misplaced decimal point contributed to the death of a newborn child in a Denver hospital according to findings from a 1996 case study that was published in Hospital Pharmacy. With that error, an infant suspected of having congenital syphilis was treated with ten times the amount of medication that was ordered by the physician. The order was 150,000 units intramuscularly, yet the patient received 1,500,000 units intravenously. The series of events that lead to the dosing, administration error and ultimate death of the child concluded with an autopsy finding no evidence of congenital syphilis. The infant had not required the medication in the first place. 3 [i] The Denver infant’s death was not an isolated case. Decimal point misplacement caused the death of an infant after the child received 15 milligrams of morphine sulfate rather than 0.15 milligrams, which was 100 times the amount prescribed.1 [vi]
In the following examples, concentration mistakes caused the deaths of several infants. A 2006 report from the Associated Press states six infants received a full adult dose, which is 1,000 times the concentration of a medication ordered in an Indiana hospital. Three of the six children died from the event.4 In 2007, actor Dennis Quaid and his wife Kimberly experienced firsthand the anxiety of a medication error when they learned about it, following the birth of their twins. Both newborns received what could have been a fatal dose of the medication Heparin, a blood thinner. As reported by CBS News, the infants received an adult dose of Heparin on two separate occasions while they were in the hospital.5 The incident prompted the Quaids to create the Quaid Foundation http://www.thequaidfoundation.org/. The Foundation is dedicated to raising the standard of safety in patient medical care. Quaid also raised his concerns regarding the near loss of his twins to Congress on May 14, 2008.6 Despite Quaid’s efforts, Heparin overdoses involving children have continued. In July 2008, an additional 14 infants received an accidental overdose of Heparin in a Corpus Christi Texas hospital. The overdose may have been responsible for the deaths of two premature babies. The event is currently under investigation.7
Reports continue to point fingers at medication errors as the culprit that adversely affects thousands of people of all ages and contributes to up to 98,000 patient deaths each year. 8 , 8[i] The resulting financial impact to the healthcare industry in the United States, according to the American Academy of Pediatrics (AAP), is estimated to exceed $100 billion annually. 8[ii] In addition, the AAP reports that “incorrect dosing is the most commonly reported error, including computation and dosage intervals”. 8[iii],[iv],[v],[vi]
Today
The 2007 report from the Institute of Medicine Quality Chasm Series reveals that medication mishaps have been found to occur at every phase of medication administration, from prescribing to monitoring reactions after administration. Drug errors are linked to multiple types of medications.3 A recent study found in Pediatrics 2008, on adverse drug events in our nation’s children’s hospitals, asserts that an average of one out of every ten hospitalized child experienced a medication error, which is substantially higher than once thought.9
On April 11, 2008, The Joint Commission issued a sentinel event alert to address medication mishaps involving children. 10 The Joint Commission acknowledges that most medications used on children are prepared for adults and must be re-concentrated and dosed for pediatric patients. The process to convert medications for children requires multiple tasks which increases the risk of committing a medication error. The Joint Commission’s report suggests weighing pediatric patients at the time of admission, or within four hours, when an emergency situation is present. The Joint Commission stresses that no high-risk drug should be administered if the patient has not been weighed unless it is an emergency, although they recognize that children who are the most at risk to medication errors are the “young, small and sick”. The IOM 2007 report on Emergency Care for Children: Growing Pains, confirms that children in emergent healthcare settings are more susceptible to medication errors.1 While medication errors are more likely to occur to children in emergent settings, it is critically important to ensure the correct weight of the child prior to any drug administration.
Medication is primarily packaged for adults. Before these medications can be used for the pediatric population, the medication must be converted to an appropriate concentration and dosage. Many medications used for children require the child’s weight in kilograms. In emergent situations, children are frequently not weighed. Instead, a length-based tape or “guess-timation” approach is taken. This type of approach leads to a risky assumption that the child’s actual weight is obtained. It is with this assumption that the medication conversion of quantity and concentration of the medication occurs.
The method most frequently used in emergency medicine to determine the approximate weight of a child is the length-based Broselow tape. This device, however, has limitations in weight approximations, partly due to the rise in child obesity. The results of one study emphasized that the Broselow tape system inaccurately estimated actual weight in one third of children.11 A device that can measure the precise weight during initial contact with a child is imperative in decreasing weight-based calculation errors.
Creative Solutions
There are tools available to help mitigate the risk of medication errors with pediatric patients. The tools include the use of a pediatric portable scale in conjunction with a medication concentration conversion chart. These devices should aid in reducing the risk of over and/or under medicating children. 12 &13
One such tool is the pediatric Crash Cards14 . The Crash Cards were created by a Board Certified Emergency Physician and a Certified Emergency Nurse, following a pediatric code in a busy emergency department. The cards list commonly used pediatric emergency medications, concentration conversions in both pounds and kilograms, and fluid resuscitation along with other important information in a 3X5 format. Reviews of this tool reveal that the pocket guide serves a critical need in pediatric emergency medicine by hospital as well as pre-hospital personnel. The Crash Cards do have restrictions. The medication conversion chart is based on the weight of the child, which requires accurate determination of the child’s body mass.
To augment the conversion chart, a pediatric scale to determine the child’s actual weight would be the second tool needed. The measuring device should be portable, and have the ability to convert pounds to kilograms. Ideally the pediatric scale should also be compact in size to accommodate use within a busy emergency department or an ambulance. Two pediatric scales are available; however, it is uncertain if the devices have been tested for use within the emergency medical system. Regardless, health care providers should consider a type of weighing device to obtain accurate pediatric weights. The following table includes the manufacturers’ descriptive information on these two products.
| Description | Weigh South Medical Model WM2300 | Detecto 8450 Digital Baby Scale |
| Suitable in permanent or portable locations | Yes | Yes |
| Weighing surface is contoured to ensure infant safety with padded handles | Yes | Yes |
| 9v battery power or AC Adapter | Yes | Yes |
| LCD display | Yes | Yes |
| Built-in measuring tape | No | Yes |
| Weights displayed in pounds & ounces or kilograms | Yes, plus ounces or pounds | Yes |
| Website |
Obtaining the child’s actual weight and utilization of a medication conversion chart to transform adult medications for pediatric use should provide a more accurate and reliable medication dosage.
Perhaps a modification of the five rights of medication administration should include two additional rights particularly for the pediatric patient. The inclusion of the Right Weight and the Right Conversion within educational programs, could serve as a catalyst to ensure the child’s weight and the medication conversion is attained. The precise weight should be measured during the initial assessment and verification thereafter to ensure actual weight was obtained and recorded correctly i.e. kilograms verses pounds. These Seven Rights for Kids Meds are: Right Patient, Right Drug, Right Medication, Right Route, Right Time, Right Weight and Right Conversion.
While literature identifies the existence and nature of medication errors, many entities note multiple recommended solutions to improve patient safety in healthcare delivery and medication safety. Examples of these include:
- Utilize websites such as American Academy of Pediatrics, Emergency Medical Services for Children and Agency for Healthcare Research and Quality;
- Encourage the use of an adverse reporting system that includes data collection and analysis for root cause;
- Convene a committee to address pediatric medication errors and incorporate participants from effected programs such as emergency medical services, emergency department and pediatric intensive care unit personnel;
- Educate staff using scenarios and/or simulators and ensure competency. Programs should include evaluating cognitive and psychomotor skills. Reeducate when any changes occur;
- Consider skill updates every 6 months; in cases where pediatric patients are infrequently treated;
When using the Broselow tape update to the 2002 edition due to important changes15
- Organize pediatric code carts/bags to facilitate equipment retrieval according to the color and coded weight class;
- Ensure proper measurement, teach staff “Red to Head”;
- Ensure laminated tapes do not exceed the tape length for proper measurement;
Encourage parent or guardian to create list(s) of all medications including over the counter medicines and the purposes for their use -
- List all medication allergies;
- Teach parents to require printed patient medication information from pharmacies;
- Educate parents about medications using fact sheets like 20 Tips to Help Prevent Medical Errors in Children from the Agency on Healthcare Quality.16
Conclusion
In summary, medication errors affect thousands of people at the cost of billions every year. When medication errors involve children, the residual effects and consequences can be devastating. With the publication of statistics that reveal the frequency of medication mishaps involving one in ten children hospitalized efforts to alleviate the traumatizing effects of pediatric medication errors must be implemented.
Medication errors concerning the pediatric population have not been adequately addressed particularly in emergency medicine and continue to be a problem almost 50 years later. While the exact number of occurrences of medication errors involving children may not be readily quantifiable, the tools to mitigate some of the risks associated with pediatric medication administration are readily available.
Knowing that medications are packaged with the adult patient in mind, efforts to determine accurate weights and subsequent changes in medication concentration and dosages that pediatric patients require are paramount. Rather than depend upon inaccurate means to guess a child’s weight, medical devices such as scales and conversion charts along with the Seven Rights for Kids Meds should be a standard part of medication administration for children.
Caring for a child in an emergency situation is stressful to any healthcare professional. The ability to utilize tools that could potentially reduce medication errors, can remove part of the angst that undermines the ability to provide appropriate medication to children when pediatric emergencies arise.
Disclaimer
The authors assume no legal liability or responsibilities for the usefulness of any product disclosed and are in no way affiliated with the vendors identified in this article.
References
1 Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Emergency Care For Children: Growing Pains. Washington, DC: The National Academies Press; 2007 [Electronic Version] pp 73,194, citing:
[i] Selbst, S.M, Levine, S., Mull, C., Bradford, K., Friedman, M. (2004). Preventing medical errors in pediatric emergency medicine. Pediatric Emergency Care 20(10):702–709.[ii] Marcin, J.P., Seifert, L., Cho, M., Cole, S.L., Romano, P.S. (2005). Medication Errors among Acutely Ill and Injured Children Presenting to Rural Emergency Departments. Presentation at the Pediatric Academic Societies Meeting, Washington, DC.[iii] Hubble, M.W., Paschal, K.R. (2000). Medication calculation skills of practicing paramedics. Prehospital Emergency Care 4(3):253–260.[iv] Fairbanks, T. (2004). Human Factors and Patient Safety in Emergency Medical Services. Science Forum on Patient Safety and Human Factors Research. Rochester, NY: University of Rochester.[v] Kozer, E., Scolnik, D., Macpherson, A., Keays, T., Shi, K., Luk, T., Koren, G. (2002). Variablesassociated with medication errors in pediatric emergency medicine. Pediatrics 110(4):737.[vi] Goldstein, A. (2001, April 20). Overdose kills girl at Children’s Hospital. The Washington Post. p. B1.
2 Independent Press-Telegram (1959, June 30).http://www.newspaperarchive.com/LandingPage.aspx? type=glpnews&search=medication%20error&img=\\na0039\6792627\45846546.html (Paid Subscription Required)
3 Institute of Medicine, Committee on Identifying and Preventing Medication Errors. Preventing Medication
Errors: Quality Chasm Series Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007 [Electronic Version] pp 43-49, citing:
Errors: Quality Chasm Series Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007 [Electronic Version] pp 43-49, citing:
[i] Smetzer, J.L., Cohen, M.R. (1998). Lessons from the Denver medication error/criminal negligence case:Look beyond blaming individuals. Look beyond blaming individuals. Hospital Pharmacy 33(6):640–657.
4 Sherman, C. (2008, March 16). Hospital error blamed for more infant overdoes. Associated Press. Retrieved 07/12/08 from http://ap.google.com/article/ALeqM5iCzTpvfMiuUq5XepYLJBAq5y5BNAD91RU5R80
5 Kroft. (2008, March 16). Dennis Quaid Recounts twins’ drug ordeal. CBS News. Retrieved 7/11/08 from http://www.cbsnews.com/stories/2008/03/13/60minutes/main3936412_page3.shtml
6 Reid. (2008, May 14). Dennis Quaid Gives Congress An Earful. Actor Advocates Lawsuits Against Pharmaceutical Companies Over Medication Errors. Companies Over Medication Errors. CBS News. Retrieved 8/3/08 from http://www.cbsnews.com/stories/2008/05/14/health/main4096047.shtml
7 Second twin dies as hospital probes heparin overdoses. n.d. CNN.com. Retrieved 7/12/08 from http://www.cnn.com/2008/HEALTH/07/10/heparin/index.html
8 Committee on Drugs and Committee on Hospital Care, American Academy of Pediatrics: Policy statement –
Prevention of medication errors in the pediatric inpatient setting. Prevention of medication errors in the pediatric inpatient setting. Pediatrics, 2003;112;431-436 doi: 10.1542/peds.112.2.431 citing:
[i] Institute of Medicine, Committee on Quality Health Care in America. To Err is Human: Building a SaferHealth System Report of the Institute of Medicine. Washington, DC: National Academies Press; 2000[ii] Schumock, G.T. (2000). Methods to assess the economic outcomes of clinical pharmacy services.
Pharmacotherapy. 20(suppl2):243S-252S
[iii] Crowley, E., Williams, R., Cousins, D. (2001). Medication errors in children: a descriptive summary of medication error reports submitted to the United States Pharmacopeia. Curr Ther Re, 26;627-640
[iv] Kaushal, R., Bates, D.W., Landrigan, C., et al. (2001). Medication errors and adverse drug events in pediatric inpatients. JAMA,. 285:2114-2120
[v] Vincer, M.J., Murray, J.M., Yuill, A,, Allen, A.C., Evans, J.R., Stinson, D.A. (1989). Drug errors and incidents in a neonatal intensive care unit. A quality assurance activity. Am J Dis Child,143:737-740
[vi] Leape, L.L., Bates, D.W., Cullen, D.J., et al. (1995). Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA, 274:35-43
9 Takata, G.S, Mason, W., Taketomo, C., Logsdon, T., Sharek, P.J. (2008). Development Testing and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Children's Hospitals. Pediatrics, Vol. 121, No. 4, pp. e927-e935 doi:10.1542/peds.2007-1779
10 The Joint Commission: Sentinel Event Alert, Preventing pediatric medication errors. Sentinel Event Alert #39,April 11, 2008.Available online: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm? (Accessed 5/12/08)
11 Nieman, C.T., Manacci, C.F., Super, D.M., Mancuso, C., Fallon, Jr., W.F. (2006) Use of the broselow tape may result in the under resuscitation of children. Academic Emergency Medicine 13 (10) , 1011–1019
doi:10.1111/j.1553-2712.2006.tb00270.x (Accessed 6/20/08)
doi:10.1111/j.1553-2712.2006.tb00270.x (Accessed 6/20/08)
recommendation is measuring a child's weight in kilograms. Medline Plus, Health Day April 11, 2008.
Available online: http://www.nlm.nih.gov/medlineplus/news/fullstory_63338.html (Accessed 5/30/08)
14 Crash Cards available from - http://www.crashcards.com/
15 Institute for Safe Medication Practices Medication Safety Alert! (2004). Broselow Tape: measuring the changes from 1998 to today. Retrieved May 14, 2007, from http://www.ismp.org/Newsletters/acutecare/articles/20040226.asp?ptr=y
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