Medication Errors in Pediatric Patients After Implementation of a Field Guide with Volume-Based Dosing

2022 ◽  
pp. 1-14
Author(s):  
Lara D. Rappaport ◽  
Geoffrey Markowitz ◽  
Steven Hulac ◽  
Genie Roosevelt
Keyword(s):  
Medication Errors ◽  
Pediatric Patients ◽  
Field Guide

Evaluation of an Electronic Dosing Calculator to Reduce Pediatric Medication Errors

2019 ◽  
Vol 58 (4) ◽  
pp. 413-416
Author(s):  
Brian Murray ◽  
Matthew J. Streitz ◽  
Michael Hilliard ◽  
Joseph K. Maddry
Keyword(s):  
Patient Safety ◽  
Medication Errors ◽  
Prospective Cohort ◽  
Pediatric Patients ◽  
Cohort Analysis ◽  
Morbidity And Mortality ◽  
Patient Visit ◽  
Significant Morbidity ◽  
Potential Source ◽  
Medication Dosage

Introduction. Adverse medication events are a potential source of significant morbidity and mortality in pediatric patients, where dosages frequently rely on weight-based formulas. The most frequent occurrence of medication errors occurs during the ordering phase. Methods. Through a prospective cohort analysis, we followed medication errors through patient safety reports (PSRs) to determine if the use of a medication dosage calculator would reduce the number of PSRs per patient visits. Results. The number of PSRs for medication errors per patient visit occurring due to errors in ordering decreased from 10/28 417 to 1/17 940, a decrease by a factor of 6.31, with a χ2 value of 4.063, P = .0463. Conclusion. We conclude that the use of an electronic dosing calculator is able to reduce the number of medication errors, thereby reducing the potential for serious pediatric adverse medication events.

Differences in adverse drug events and medication errors among pediatric inpatients aged <3 and ≥3 years: The JADE study

2021 ◽  
pp. 251604352110467
Author(s):  
Jiro Takeuchi ◽  
Mio Sakuma ◽  
Yoshinori Ohta ◽  
Hiroyuki Ida ◽  
Takeshi Morimoto
Keyword(s):  
Hospital Stay ◽  
Medication Errors ◽  
Primary Outcome ◽  
Pediatric Patients ◽  
Adverse Drug Events ◽  
Medication Use ◽  
Skill Levels ◽  
Linguistic Skills ◽  
Events Study

Background Adverse drug events (ADEs) are defined as any injuries due to medication use. We hypothesized that the incidences of ADEs and medication errors (MEs) could be associated with linguistic skills of pediatric patients. Methods We analyzed data from the Japan Adverse Drug Events study on pediatric inpatients. This study included inpatients aged one months and older and less than seven years old. We compared the primary outcome of ADEs and MEs between patients aged under three years and three years and older as children typically do not acquire sufficient linguistic skills until around three years of age. Results This study included 639 patients; 412 (64%) patients aged under three years and 227 (36%) patients aged three years and older. We identified 241 ADEs in 639 patients; 152 ADEs among patients aged under three years (37 ADEs per 100 patients) and 89 ADEs among those aged three years and older (39 ADEs per 100 patients). ADEs among patients aged under three years were less likely to be found (49 ADEs) during their hospital stay than those aged three years and older (20 ADEs) ( P = 0.02). Among 172 MEs identified in 639 patients, 25 MEs (15%) resulted in ADEs; 23 (92%) occurred to those aged under three years and two (8%) occurred to those aged three years and older ( P = 0.0008). Conclusion ADEs were less likely to be found and MEs resulted in ADEs more frequently in patients under three years old, and these differences could be explained by differences in their linguistic skill levels.

scholarly journals Evaluation of medication errors in pediatric patients using antibiotics

2021 ◽  
Vol 63 (6) ◽  
pp. 970
Author(s):  
Nesligül Özdemir ◽  
Emre Kara ◽  
Ayşe Büyükçam ◽  
Kübra Aykaç ◽  
Ayçe Çeliker ◽  
...  
Keyword(s):  
Medication Errors ◽  
Pediatric Patients

scholarly journals Strategies for Implementing Pediatric Dose Standardization: Considerations From the Vizient University Health System Consortium Pharmacy Network Pediatric Pharmacy Committee

2021 ◽  
Vol 27 (1) ◽  
pp. 19-28
Author(s):  
Christopher T. Campbell ◽  
Kristin H. Wheatley ◽  
Leanne Svoboda ◽  
Courtney E. Campbell ◽  
Kelley R. Norris
Keyword(s):  
Information Technology ◽  
Medication Errors ◽  
Medication Safety ◽  
Pediatric Patients ◽  
Pediatric Population ◽  
Successful Implementation ◽  
Institutional Level ◽  
Pediatric Dose ◽  
Reduce Medication Error ◽  
Survey Results

Pediatric patients are at a heightened risk for medication errors due to variability in medication ordering and administration. Dose rounding and standardization have been 2 practices historically used to reduce variability and improve medication safety. This article will describe strategies for implementing pediatric dose standardization. Local practice often dictates the operational decisions made at an institutional level, leading to a lack of a standard methodology. Vizient survey results demonstrate there is wide variation in dose standardization and ready-to-use (RTU) practices although most responding institutions have attempted to limit bedside manipulation to reduce medication error. There are many barriers to consider before pursuing dose standardization at an institution. These include selecting medications to standardize, calculating appropriate standardized doses, preparing RTU products, and supplying the products to the patient. Strategies to overcome implementation issues are described as well as identification of knowledge gaps related to the preparation and use of RTU products in the pediatric population. There is opportunity to enhance an institution's ability to provide RTU medications. Although there are several barriers, those that have had successful implementation have leveraged their information technology systems, garnered multidisciplinary support, and customized their practice to meet their operational demands.

scholarly journals Improving Safety of Intravenous Prostacyclin Administration to Pediatric Patients With Pulmonary Hypertension

2019 ◽  
Vol 39 (4) ◽  
pp. e1-e7 ◽  
Author(s):  
Julia McSweeney ◽  
Emily Rosenholm ◽  
Katherine Penny ◽  
Mary P. Mullen ◽  
Thomas J. Kulik
Keyword(s):  
Pulmonary Hypertension ◽  
Medication Errors ◽  
Pediatric Patients ◽  
Severe Disease ◽  
Therapeutic Index ◽  
Quality Improvement Initiative ◽  
Chi Square ◽  
Safety Reporting ◽  
Life Threatening ◽  
Chi Square Analysis

Background Pulmonary hypertension is a rare, life-threatening disease with limited therapeutic options and no definitive cure. Continuous intravenous prostacyclin therapy is indicated for treatment of severe disease. These medications have a narrow therapeutic index and a brief half-life; therefore, administration errors can be lethal. Objective To reduce medication errors through an inpatient program to improve, standardize, and disseminate continuous intravenous prostacyclin therapy practice guidelines. Methods Data were collected from the electronic safety reporting system of a single hospital to determine the number and types of continuous intravenous prostacyclin therapy errors that were reported over an 8-year period. A clinical database and hospital pharmacy records were used to determine the number of days on which hospitalized pediatric patients received the therapy. Interventions A nursing-directed quality improvement initiative to enhance the safety of continuous intravenous prostacyclin therapy for pediatric patients was begun in January 2009. Efforts to improve safety fell into 4 domains: policy, process, education, and hospital-wide safety initiatives. Results The number of therapy errors per 1000 patient days fell from 19.28 in 2009 to 5.95 in 2016. Chi-square analysis was used to compare the result for 2009 with that for each subsequent year, with P values of .66, .35, .16, .09, .03, .12, and .25 found for 2010 through 2016, respectively. Conclusions The trend in reduction of continuous intravenous prostacyclin therapy errors suggests that proactive processes to standardize its administration, emphasizing both policy and education, reduce medication errors and increase patient safety.

scholarly journals Medication Discrepancy Risk Factors for Pediatric Patients With Epilepsy at Hospital Admission

2021 ◽  
Vol 26 (4) ◽  
pp. 384-394
Author(s):  
Katie Louiselle ◽  
Lory Harte ◽  
Charity Thompson ◽  
Damon Pabst ◽  
Andrea Calvert ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Hospital Admission ◽  
Medication Errors ◽  
Pediatric Patients ◽  
Medication History ◽  
Medication Discrepancies ◽  
Improvement Project ◽  
Medication Discrepancy ◽  
Increased Risk ◽  
Patients With Epilepsy

BACKGROUND Children with epilepsy are at increased risk of medication errors due to disease complexity and administration of time-sensitive medication. Errors frequently occur during transitions of care between home and hospital, a time when accuracy of medication history lists is difficult to ascertain. Adverse events likely from medication discrepancies underscore the importance of improving medication reconciliation upon inpatient intake. This quality improvement project was designed to evaluate and optimize the current medication history process in epileptic patients upon hospital admission at a pediatric academic hospital. METHODS A retrospective chart review was conducted on 30 patients with epilepsy admitted in during April, July, and October 2018 to identify unintentional medication discrepancies among 6 sources: documented medication history, inpatient orders from the electronic medical record, outpatient clinic notes, inpatient history and admission document, phone message records, and external insurance claims. RESULTS A total of 63% percent of patients had at least 1 unintentional medication discrepancy. Most discrepancies occurred with daily maintenance anticonvulsants (63%). The most common types were omission of medication history (31%) and inpatient order omissions (27%). The number of medication histories completed with at least 1 discrepancy varied across pharmacists, nurses, and physicians, yet differences were not statistically significant. CONCLUSIONS Our study found a higher incidence of anticonvulsant discrepancies compared with previous studies. This quality improvement initiative identified the absence of a standardized process as the root cause for the high incidence of anticonvulsant discrepancies in pediatric patients with epilepsy at hospital admission.

scholarly journals ASSESSMENT OF MEDICATION ERRORS IN PEDIATRICINPATIENT DEPARTMENT OF A PRIVATE HOSPITAL

2017 ◽  
Vol 9 (6) ◽  
pp. 70 ◽  
Author(s):  
P. Nikhithasri ◽  
M. Ramya ◽  
P. Kishore
Keyword(s):  
Observational Study ◽  
Medication Errors ◽  
Nursing Staff ◽  
Medication Safety ◽  
Prospective Observational Study ◽  
Private Hospital ◽  
Pediatric Patients ◽  
Patient Records ◽  
Prescribing Errors ◽  
Direct Communication

Objective: To assess the overall rate and incidence of medication errors in pediatric inpatients and to determine the importance of pharmacist participation in medication errors.Methods: A prospective observational study has been conducted in a ‘private childrens hospital’ for 6 mo at Warangal, Telangana. Patients who are ≤18 ywere considered. Data was collected from patient records, direct communication with patient and their care givers.Results: Among 400 patients with 2,461 medication orders,1381(56%) errors were found. Patients were more exposed to AME(33.7) caused by the nursing staff, followed by PME-21.5,CME-0.6,DME-0.2 in incidence with the 95% CI.Conclusion: Pediatric patients are more exposed to administration errors and prescribing errors. Pediatricians and Pharmacists should develop effective programs for safe administration of medications, report medication errors, eliminate barriers in reporting medication errors, encourage a non-punitive reporting culture and create an environment of medication safety for all hospitalized pediatric patients

scholarly journals The Burden of Preventable Adverse Drug Events on Hospital Stay and Healthcare Costs in Japanese Pediatric Inpatients: The JADE Study

2021 ◽  
Vol 15 ◽  
pp. 117955652199583
Author(s):  
Hitoshi Iwasaki ◽  
Mio Sakuma ◽  
Hiroyuki Ida ◽  
Takeshi Morimoto
Keyword(s):  
Hospital Stay ◽  
Medication Errors ◽  
Healthcare Costs ◽  
Pediatric Patients ◽  
Adverse Drug Events ◽  
Length Of Hospital Stay ◽  
Sensitivity Analyses ◽  
National Burden ◽  
The Individual ◽  
Preventable Ades

Background: Adverse drug events (ADEs) are a burden to the healthcare system. Preventable ADEs, which was ADEs due to medication errors, could be reduced if medication errors can be prevent or ameliorate. Objective: We investigated the burden of preventable ADEs on the length of hospital stay (LOS) and costs, and estimated the national burden of preventable ADEs in pediatric inpatients in Japan. Methods: We analyzed data from the Japan Adverse Drug Events (JADE) study on pediatric patients and estimated the incidence of preventable ADEs and associated extended LOS. Costs attributable to extended LOS by preventable ADEs were calculated using a national statistics database and we calculated the effect of preventable ADEs on national cost excess. Results: We included 907 patients with 7377 patient-days. Among them, 31 patients (3.4%) experienced preventable ADEs during hospitalization. Preventable ADEs significantly increased the LOS by 14.1 days, adjusting for gender, age, ward, resident physician, surgery during hospitalization, cancer, and severe malformation at birth. The individual cost due to the extended LOS of 14.1 days was estimated as USD 8258. We calculated the annual extra expense for preventable ADEs in Japan as USD 329 676 760. Sensitivity analyses, considering the incidence of preventable ADEs and the length of hospital stay, showed that the expected range of annual extra expense for preventable ADEs in Japan is between USD 141 468 968 and 588 450 708. Conclusion: Preventable ADEs caused longer hospitalization and considerable extra healthcare costs in pediatric inpatients. Our results would encourage further efforts to prevent and ameliorate preventable ADEs.

scholarly journals Approach to the Pediatric Prescription in a Community Pharmacy

2011 ◽  
Vol 16 (4) ◽  
pp. 298-307
Author(s):  
Sandra Benavides ◽  
Donna Huynh ◽  
Jill Morgan ◽  
Leslie Briars
Keyword(s):  
Community Pharmacy ◽  
Medication Error ◽  
Pediatric Patient ◽  
Medication Errors ◽  
Community Pharmacist ◽  
Systematic Approach ◽  
Pediatric Patients ◽  
Community Pharmacists ◽  
Patient Specific ◽  
Social Differences

Pediatric patients are more susceptible to medication errors for a variety of reasons including physical and social differences and the necessity for patient-specific dosing. As such, community pharmacists may feel uncomfortable in verifying or dispensing a prescription for a pediatric patient. However, the use of a systematic approach to the pediatric prescription can provide confidence to pharmacists and minimize the possibility of a medication error. The objective of this article is to provide the community pharmacist with an overview of the potential areas of medication errors in a prescription for a pediatric patient. Additionally, the article guides the community pharmacist through a pediatric prescription, highlighting common areas of medication errors.

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