Hospitalized infants and children frequently are at risk for IV medication errors, which can occur at any point during the medication use process—from ordering by the physician, to dispensing by the pharmacist, to administration by the nurse. To eliminate IV medication errors in the pediatric population, comprehensive safety measures and corrective actions must be implemented at every point in the care continuum, a task that can only be accomplished with a thorough understanding of the unique difficulties and challenges involved in pediatric patient care.
Essential Pediatric Safety Considerations
Determine Correct Weight
Many of the risks associated with caring for pediatric patients are related to physical size differences, and thus dosing variations, in this population. Most decisions made regarding drug ordering, verification, dispensing, and administration depend on patient size, so the importance of obtaining the correct weight for pediatric patients cannot be overemphasized; many medication errors occur when this step is missed. Correlating the patient’s normal weight for his or her age is vital. If a weight seems too low or too high for the age of the patient, check with the physician or the nurse to verify its accuracy. Recording weight in kilograms instead of pounds, and vice versa, is a common error to be aware of. Check pediatric reference tables specifying patient size to patient age if you are unfamiliar with this information. Of course, some patients may be either under- or overweight or large or small for their ages, but nothing should be assumed; always verify with the prescriber or nurse.
Verify Pediatric Doses
Pediatric doses of IV and oral medication should never be estimated or extrapolated from adult dosing, as children metabolize and excrete drugs differently from adults. As with the adult population, different indications have different dosing recommendations; ensure the dosing is correct not only for the weight of your patient, but also for the prescribed indication. For example, a dose of ceftriaxone for an infant with meningitis would be higher than a dose of ceftriaxone for the same infant with bacteremia. Checking every medication dose (IV or oral) against a pediatric reference is absolutely necessary.
Beware of Decimal Points
When checking doses, be mindful of decimal points and dosage units. Some medication infusions change between dosage units depending on the rate of infusion or indication. For example, vasopressin infusion can be dosed in milliunits/kg/minute, units/kg/minute, milliunits/kg/hour, and units/kg/hour; therefore, mislabeling the dose with incorrect units of measure can lead to significant overdose or underdose of the medication. Always double-check your calculations. When in doubt, ask a colleague to confirm that your calculations are correct.
Standardization Reduces Pediatric IV Errors
Minimizing the risk of errors in all patient populations can be accomplished through standardization of policies and procedures, and this is especially true for pediatric IV preparations. Whether your institution has a dedicated children’s hospital or a pediatric unit, specific policies and procedures should be created to standardize medication use and administration to pediatric patients. Substantial differences exist between adult and pediatric populations, and so methods of managing IV drug therapy on a pediatric unit and on an adult unit will differ. This is especially valid—and becomes more complicated—if your hospital has a NICU and a general pediatric unit; as the pediatric population becomes more diverse, policies must be created to address specific patient populations. These strategies can range from the simple, such as defining weight cutoffs to use in per kilogram dosing, to the more complex, such as the preparation, dispensing, and administration of insulin drips to infants in the NICU. Fewer mistakes will occur as a result of misinterpretation if policies are extremely specific.
Educating staff on newly developed guidelines is imperative. Such information can be shared by e-mailing it directly to department heads for distribution to staff members, or posting the new policy information on the hospital’s intranet for easy staff access. Depending on the complexity of the topic, staff training on new policies and procedures can take place during staff meetings; include a brief overview and instructions on where to obtain more detailed information. Alternatively, training can be provided during designated education sessions that will allow staff to participate in more in-depth discussions. To maintain staff knowledge or present new information, you may choose to prepare yearly (or more frequent) competencies with a short final exam presented to ensure staff understanding.
Disseminating information to staff can be particularly challenging at an institution with large departments or frequent staff rotation and/or turnover. However, once a policy is formally approved at an institution, staff must be informed of and must comply with the new policy.
Pediatric IV Medication Preparation
To maximize safety, four key points must be considered before an IV medication is prepared and dispensed to a pediatric patient: the size of the patient, the concentration of medication for that patient population, the size of the vial in which to dispense, and the method of infusion. To illustrate these points, note the differences in preparation required for two patients: a 2-week-old, 4-kg infant and an 8-year-old, 40-kg patient.
Size of Patient: Depending on the size of your patient, it is necessary to determine the concentration of the drug, total volume to be dispensed, infusion instructions, and so on.
Medication Concentrations: Adult drug concentrations frequently can be used for older children, which eases the IV drug preparation for the pharmacy staff without affecting the safety of the patient. In a 40-kg patient, there is less concern for fluid overload with higher volume drugs or issues with insufficient fluid flow in the medication pump to deliver the drug. For example, assume that the two patients are prescribed a midazolam drip to run at 0.05 mg/kg/hr, and that the standard concentration for the midazolam drip is 5 mg/mL. The rate for the 4-kg infant will be 0.04 mL/hr and for the 40-kg patient will be 0.4 mL/hr. Depending on the pumps used, a rate of 0.04 mL/hr might be impossible to run, whereas a rate of 0.4 mL/hr would be suitable. The pump will limit which drug concentrations can be supplied to a specific patient population. Medications should not be too dilute as to cause fluid imbalance in the youngest population, and it is necessary to determine whether a particular concentration is safe to be administered to a specific patient population. Oftentimes the recommended concentrations for medications will differ between a neonate and a pediatric patient. Check reliable pediatric references to verify the recommendations for concentrations. It is highly recommended to standardize concentrations and create IV preparation sheets.
Size of Vial: Strive to provide most IV medications in unit dose to ensure safe dosing; if unit dose is not available, dispense only the amount required to make up the dose. Practices such as hanging a standard-sized bag (eg, potassium chloride 20 meq/100 mL) and having the nurse set the pump to infuse a partial amount from the bag (eg, only 10 meq/50 mL) should be avoided, as this can lead to mistakes in administration and potential patient harm. Every IV dose dispensed should be patient-specific.
Infusion Method: When preparing IV infusions, ensure that the IV drip sizes being prepared are sufficient to deliver the drug before the drip expires; for example, if a drip will expire 48 hours from preparation, ensure the drip will not require changing by nursing because the drug will run out before the 48-hour mark. This will save nursing and pharmacy time, as well as decrease the probability of line infection due to frequent, unnecessary line access and manipulation.
IV Infusion Times
Another effective way of preventing IV medication errors in pediatric patients is to standardize IV medication infusion times. While this process can be time-consuming and tedious, it will ensure pediatric patient safety. Pediatric patient-specific concentrations and infusion times in smart pumps must be differentiated from those for adults; some hospitals have a designated IV medication library with pediatric or neonatal medications, while others have specific pediatric entries within the adult library. Even when the drug concentration and infusion time is the same for both adult and pediatric patients, there should be a specific entry for the pediatric patient, as the nursing staff will not assume that the adult entry should automatically be used for a child and will look for a pediatric-specific drug entry in the pump library.
IV Drug Preparation Sheets
Variations in IV medication preparation will contribute to the increased incidence of administration errors, as well as questions from the nursing staff. To ensure high quality and uniformity in preparation and dispensing of IV medications, it is highly recommended that you create IV drug preparation sheets. Preparation of documents for each and every IV drug that is dispensed to the pediatric population can be time-consuming, but these materials are useful to staff and help ensure accurate drug preparation.
IV Push Lists
Having a standardized IV push list for injectable medications—simply the name of the drug and the recommended time of administration—can prevent errors and adverse drug events in pediatric patients. Again, do not extrapolate a pediatric list from the adult list, since many medications are pushed at a different rate in pediatric patients or are not recommended to be pushed at all. Once such a list is formally approved at your institution, staff education will be crucial to ensure that health care providers understand the purpose of this list and its correct use.
Order forms can be tailored to help prevent adverse events from occurring, but accomplishing this will depend on the culture of your institution and the limitations of your computerized prescriber order entry system. If your system allows, create a separate ordering view for the general pediatric unit, PICU, and NICU, with each ordering view containing only the medications and IV drips that are permitted for use in that designated patient group. Likewise, within that view you can restrict access to IV medication concentrations and drip sizes to those tailored for that population. If that option is not available in your system, create separate entries that provide a prompt for the designated patient population for that entry (eg, Fentanyl Drip–Adults; Fentanyl Drip–PICU; Fentanyl Drip–NICU). It is also possible to add suggestions and pre-fill certain fields in the ordering screens to create a safer, easier ordering process. For example, drip doses and rates for children tend to be expressed in mg/kg/hr, while in adults they generally are expressed in mg/hr; an auto-fill feature can ensure the correct doses and rates are entered.
Medical care of children is more complicated than care of adults, and requires constant attention to detail by every team member involved to ensure proper treatment and safety. Fostering an understanding in the pharmacy of the fundamental issues in pediatric care and standardizing the ordering tools will assist in improving care for the children and infants in your facility. As pharmacists, it is our duty to ensure that the most vulnerable patients’ medication needs are recognized and protected. Keep in mind that children are not just little adults; the care provided to them must be tailored to their specific needs.
Malgorzata Michalowska-Suterska, PharmD, BCPS, is a pediatric clinical pharmacy specialist at Maria Fareri Children’s Hospital at Westchester Medical Center in Valhalla, New York, and her interests focus on pediatric critical care. She graduated from the University of Connecticut School of Pharmacy and is a member of the American College of Clinical Pharmacy and the Pediatric Pharmacy Advocacy Group. Malgorzata also holds an adjunct faculty appointment at St. John’s University College of Pharmacy.
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