In this study, use of a dedicated pediatric fax machine with coloured paper led to increased scrutiny of pediatric medication orders. Pediatric patients are more likely to experience medication incidents, because of huge variations in weight, from less than 0.5 kg to more than 100 kg. As such, each dose must be calculated individually, taking into account the patient’s age, maturity, clinical condition, weight or body surface area, and available formulations. In addition, with their lower physiologic reserves, pediatric inpatients may have limited ability to buffer errors such as overdoses.
Several error-prevention strategies have been implemented at other hospitals. One approach requires a variety of human resources, including presence of a clinical pharmacist, pharmacists’ participation in patient rounds, monitoring by pharmacists of ordering and transcribing, and increased communication among health care professionals. With a limited number of pharmacists who specialize in pediatrics practising in adult hospitals, it can be difficult to fulfill all of these desired roles for pediatric patients. Therefore, the dispensing pharmacist has an increased role in scrutinizing pediatric orders for appropriate dosing. However, in hospitals that
focus on caring for adults, the dispensing pharmacist often has limited knowledge about pediatric inpatients. In addition, some adult-focused pharmacists may perceive that orders written by a pediatrician do not need dose validation. Dispensing pharmacists at the author’s hospital receive no training or orientation on reviewing pediatric orders and performing dose validation. Each dispensary pharmacist reviews 250 to 300 orders per shift, of which only a handful are pediatric orders. In addition, the dispensing pharmacist has no opportunity to directly observe the consequences to the patient of pharmacy- related medication errors and thus may not realize the significance of such errors. The lack of pediatric focus, appropriate training, and exposure to pediatric patients and their medication orders leads to a lack of compliance with the dose-validation procedures that are routinely performed in pediatric hospitals. Cina and others found that pharmacists’ accuracy in detecting errors was only 79%; therefore, standardized processes are beneficial in reducing incidents.
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Another approach to reducing error involves technology, for example, computerized physician order entry, electronic decision support, prescription transmission systems, and medication administration records; these options may be suitable for some sites. In addition, the use of robots for dispensing, automated dispensing machines, unit-dose systems, bar-coding for patients and medications, and “smart” IV devices have also been suggested. Although technologic advances may help to reduce some medication errors, they will not eliminate all errors. The potential for the use of technology to generate errors must also be considered. For example, at the author’s hospital, receiving all orders by fax transmission was considered a technologic advance when it was first implemented. However, there was little consideration of the possibility that pediatric dosing errors would be missed. Adding a second fax machine dedicated to pediatric orders increased the proportion of pediatric orders checked by a pharmacist from 47.9% to 64.1%; when teenagers were excluded, the proportion increased from 49.6% to 74.5%. Although optimal dose checking (i.e., checking of all doses for pediatric patients and validation against standard milligram per kilogram or milligram per square metre doses) was not achieved with this small change, the decrease in the number of orders missed and the increase in the number of orders with doses checked were both greater than anticipated. The frequency of errors involving incorrect instructions and formulations was reduced from 9.2% to 4.1%, which was perceived as a substantial decrease. To further increase the number of orders that are appropriately checked by dispensary pharmacists, additional changes need to be considered, including an educational component on how to perform dose validation and discussion of medication errors and their consequences.
The limitations of this study included the limited number of orders reviewed, the difference in numbers of orders examined for the 2 periods (before and after implementation) when stratified by age, and the review of only those pediatric orders that were received from the pediatric wards and the NICU (pediatric orders from the emergency department were not included). In addition, the focus was on appropriate pharmacist scrutiny of pediatric medication orders; any effects on patient outcomes were not examined.
The complexity of dosing for pediatric patients requires a system that will ensure appropriate scrutiny of orders. In hospitals that focus on adult care, the system must help pharmacists to recognize pediatric orders requiring dose checks, precise measurements, and appropriate formulations. Scrutiny of pediatric orders by pharmacists increased after implementation of a dedicated fax machine. However, because of a lack of pediatric focus and lack of familiarity with dose-validation procedures, this intervention was not enough on its own to achieve 100% dose validation. An educational component outlining a procedure for reviewing pediatric orders and describing the significance of medication errors in this population may increase compliance with dose validation.
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