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Medication Safety Monday – Part 5


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Nearly ten years ago, I undertook an project for my Pharmacy degree, with the title “Minimising Medication Errors for Paediatric Inpatients”. The TGA’s recent alert about Paracetamol dosing and events in in the national news have made me consider some of the newer literature in and around the of inpatient medication safety in children. This post is the final in a series of five brief reviews.

Bottom Line:

  • We have a responsibility to make medications as safe as possible
  • Think about the ‘rights’ of medication safety
  • Make time to prescribe safely
  • Use reputable references and show your working
  • Communicate with your colleagues about medications
  • Strive to be safe!

Throughout the series we’ve identified that paediatric inpatients are at higher risk of medication errors as ADEs that their adult counterparts. What then, can we do to reduce Medication Errors? Firstly, this 2003 article published in Pediatrics re-works the data obtained in the Kaushal prospective study. Again, remember that this data set was sponsored by one of the inventors of a prescribing software.

 Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, Goldmann DA, Bates DW.

In their data set (the same as Kaushal et al), the most frequent type of medication error was a dosing error; ~28% of all errors, including omissions, dose not documented and over-orders.

Fortescue et al looked at a number possible interventions to reduce errors & ADEs (and the % of error’s they’d prevent); the most successful of which were on-ward pharmacists (88.3%) , computer prescribing (with and without decision support) (~75.8%) and improved communication (85.8%). The authors boldly suggest that incorporating all three of these interventions would have prevented 96.7% of potentially harmful errors.

Fortescue et al have really looked at some big picture, big ticket items, and they’re worth considering. At a more personal level, how can we improve safety as individuals and small teams?

As with resuscitation, medication safety is about knowing the basics and doing them really well. In much of the medication safety literature, there’s an emphasis on the “rights” of medication safety. That is,

  • right patient
  • right drug
  • right time
  • right route
  • and right dose

I’ve seen a number of different posters on the wall of medication rooms, in pharmacies et cetera with variations of the above.

On that note, the culture in nursing appears quite different to that of doctors. At the facilities I’ve worked, there have been a number of nursing-driven interventions to improve safety around medications, above what is considered the ‘general standard’. These include ‘protected time’ when preparing medications, where there’s an interruption-free zone, the preparation ‘red apron’, which clearly signals that the nurse is engaged in medication preparation and a well upheld culture of ‘do not disturb’, around this time.

This is quite different for medical staff, for whom prescribing (and specifically initiating) is often done on the ward round, rather than a dedicated time. So, some common sense advice for prescribing:

  • Write (and re-write) prescriptions/orders without interruption
  • Consider the indications & risks vs benefits of prescribing every medication
  • Look up (confirm) the dose from a standard reference
  • Weight based dosing is the rule for paediatrics
  • Show your working (most charts have space) – be clear about the frequency
  • Identify a review point for short term therapies
  • Omissions – remember to prescribe all of the child’s medications!
  • Think about the rights

References commonly used Frank Shann’s Drug Doses, AMH Children’s Dosing Companion, BNF for children. Find out what your local preferred reference is and know your way around it.

In the acute setting, make use of Algorithm chards (make sure they’re current!), Broselow tapes, Code books. Monash Childrens’ Hospital in Victoria recently made their Paediatric Emergency Medication Book available; you can check it out here.

Fortescue et al mention ‘improved communication’ – on a day to day basis, this is something we can all improve. From letting your nursing staff know you’ve initiated or changed a new therapy to encouraging an environment where your prescribing can be queried if it ‘doesn’t seem right.’ I mention this as a key point because, certainly in the smaller Paeds wards of regional hospitals, the majority of admissions are in and out before the pharmacist gets anywhere near their chart. Being able to talk to each other adds in extra layers of Swiss cheese.

Overnight admissions can be a vulnerable time to be taking a medication history & writing a busy medication chart – consolidate your colleague’s work and medication history as soon as practicable the next morning.

One final point is regarding multiple medications; whilst our adult colleagues will readily recount the myriad of medications many of their patients take, for kids, it’s such a different situation. We less often see a child on ten or so medications. When prescribing/writing or re-writing medication orders we need to be aware of our unfamiliarity and greater potential for error.

The AAP’s 2003 position paper for those involved in the care of children. With regard to prescribers, they make twenty-five recommendations, which I’ve included here in its entirety.

Stucky ER; American Academy of Pediatrics Committee on Drugs; American Academy of Pediatrics Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003 Aug;112(2):431-6.

Prescriber Actions and Guidelines

Physician prescriptions and drug orders are a means of communicating, so they must be legible, clear, and unambiguous. The following steps help ensure that medication orders communicate safely and effectively.

  • Confirm that the patient’s weight is correct for weight-based dosages.
  • Ensure that weight-based dose does not exceed the recommended adult dose.
  • Ensure that calculations are correct.
  • Write weight on each order written.
  • Include dose and volume when appropriate; specify exact dosage strength to be used.
  • Write intravenous fluid orders clearly, ensuring that additives are quantified per liter and rates are noted per hour.
  • Identify patient drug allergies and inquire about any changes at each encounter. Note any old and new allergies on orders.
  • Write out all instructions rather than using abbreviations except for those approved by the institution.
  • Avoid vague instructions (e.g. “take as directed”); make instructions specific (e.g. “take 1 tablet each morning”).
  • Avoid use of a terminal zero to the right of the decimal point (e.g. use 5 rather than 5.0) to minimize 10-fold dosing errors.
  • Use a zero to the left of a dose less than 1 (e.g. use 0.1 rather than .1) to avoid 10-fold dosing errors.
  • Avoid abbreviations of drug names (e.g. MS may mean morphine sulfate or magnesium sulfate).
  • Use generic medication names rather than trade names.
  • Spell out dosage units rather than using abbreviations (e.g. milligram or microgram rather than mg or microgram rather than mg or mcg; units rather than U)
  • Ensure that prescriptions and signatures are legible, and include prescriber’s name printed next to the signature, along with a contact number.
  • Avoid use of verbal orders whenever possible. If verbal orders are to be used, spell out common error words (e.g. fifteen vs fifty).
  • Utilize CPOE and standardized order sets when available.

Prescriber Education and Communication

  • Stay current and knowledgeable concerning changes in medications and treatment of pediatric conditions.
  • Utilize pharmacist consultation if available. An example is for adjustment of dose or dosing interval for neonates or for body surface area.
  • Review the patient’s existing drug therapy, including any over-the-counter medications or herbal or dietary supplements, and inquire about old and new allergies before prescribing medications.
  • Remain familiar with individual hospital medication ordering systems.
  • Ensure that drug orders are complete, clear, unambiguous, and legible. Discuss medication changes with nursing and other appropriate staff and families.
  • When possible, speak with the patient or caregiver about the medication that is prescribed and any special precautions or observations that should be noted, such as allergic or hypersensitivity reactions. Encourage patients and families to ask questions about all medications ordered.
  • Report errors and encourage blame-free error reporting. Ensure that all staff members understand the method of reporting and are knowledgeable about JCAHO reporting rules.
  • Be aware of ongoing tracking systems and pharmacy programs and be actively involved in system development and review.

Medication safety isn’t the enthralling, high adrenaline side of medicine. No helicopters, no “cutting to air”. It is one of the cornerstones of care. When we prescribe, we aim to help our patients. Occasionally there is harm from this; sometimes unavoidable, sometimes avoidable.

It strikes to the heart of medicine that we should do no harm; improving and fine-tuning medication (and patient) safety is a duty we all have to our patients.

About the authors

  • A General Paediatrician and Adolescent Medicine Fellow based in Queensland, Australia, Henry is passionate about Health Systems and Complex Care, with a strong interest in Medical Education & Clinical Teaching. His 'Dad jokes' significantly pre-date fatherhood, and he stays well by running ultramarathons. @henrygoldstein | + Henry Goldstein | Henry's DFTB posts


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