USP Issues Parent Recommendations To Help Prevent Medication Errors in Children
Weight Miscalculations Recognized as Frequent Problem in Pediatric Medication Dosing
Rockville, Maryland — The United States Pharmacopeia (USP) today announced recommendations for preventing medication errors when children are in the hospital and at home.
USP’s Center for the Advancement of Patient Safety (CAPS) created the recommendations after analyzing medication error data from its databases. Pediatric medication errors can often occur, for example, when a decimal point is misplaced in a medication dose or an incorrect weight conversion from pounds to kilograms is made. Health care practitioners must consider a child’s age, weight, medication dosing frequencies, and a number of other factors to help ensure the safety of young patients.
“Medications for children are usually dosed by weight in kilograms, which means that adult dosages are often diluted based on weight conversions from pounds to kilograms,” said Diane Cousins, R.Ph., vice president of CAPS at USP. “Because weight calculations are recognized as a frequent problem in pediatric medication dosing, parents can help prevent errors by knowing their child’s weight in kilograms and re-confirming with their child’s doctor that their child is receiving the proper dosage.”
“Parents should also inform the health care provider of any and all allergies their child has and make sure the provider lists them on their child’s medical chart,” added Cousins. “In the home, it is essential that parents use their senses to identify their child’s medication by size, shape, color, smell, and sight. If their child is old enough, parents can also teach them to use their senses as well.”
Tips for Parents: Preventing Medication Errors
While medication errors can happen to any patient at any age, the consequences can be far more devastating when children are involved. With this in mind, USP offers parents the following tips to help prevent medication errors from happening to their children:
- On admittance to the hospital, provide the health care practitioner (HCP) with an up-to-date list of all medicines (prescription and over-the-counter) and dietary supplements that your child is taking. This will help minimize medication errors and prevent drug interactions during your child’s hospital stay.
- Make sure your child’s HCP is aware of any allergies your child may have. For life-threatening allergies, be sure that your child wears a MedicAlert bracelet at all times.
- Medications administered to children are based on the child’s weight in kilograms. For purposes of preparing appropriate dosages of medicines, your child’s weight in pounds must be divided by 2.2 in order to convert his or her weight into kilograms. Be aware of this calculation and/or your child’s weight in kilograms, and reconfirm the correct dosage with your child’s HCP if you have concerns.
- Be sure that you are provided with verbal and written information about your child’s medications, the common side effects, and the adverse events that should be reported to your child’s HCP.
- Pay close attention to how your child is feeling while in the hospital. Notify the HCP immediately if you notice any negative side effects from the administered medications, such as sudden difficulty in swallowing or breathing.
- If your child is given a liquid medication to take after release from the hospital, be sure you are provided with an appropriate measuring device and instructions to ensure proper medication doses.
- In case of an emergency, be sure that your child’s school has a list of any medical conditions or allergies your child may have.
“Recommendations such as those issued by the USP should help to alert both parents and health care providers of ways to prevent such serious medication errors,” said Dr. Phil Walson, who is the director, pharmacology division and clinical trials office at Cincinnati Children's Hospital Medical Center and a member of the American Academy of Pediatrics. “Parents and their children have the right to expect that health care providers will do everything possible to avoid such errors.”
In December 2002, USP released an analysis of medication errors captured in 2001 by MEDMARX, the anonymous, national reporting database operated by USP. This third annual report, Summary of Information Submitted to MEDMARX in the Year 2001: A Human Factors Approach to Medication Errors, is the most comprehensive compilation of medication error data submitted by hospitals and health systems nationwide.
Of the 105,603 errors documented by MEDMARX, 3,361 errors, or 3.2 percent of total errors, involved pediatric populations (birth to 16 years). Although the majority of errors were corrected before causing harm to the patient, 190 errors, or 5.7 percent of total errors, resulted in patient injury. Of this number, 156 resulted in temporary harm to the patient and required intervention, 31 required initial or prolonged hospitalization, one required intervention to sustain life, and two errors resulted in a patient’s death.
Recently, USP’s Pediatric Expert Committee and the Safe Medication Use Expert Committee released recommendations for health care professionals to help prevent pediatric medication errors, which may be applied and adopted in various health care settings. The Pediatric Expert Committee and the Safe Medication Use Expert Committee comprise national experts representing medicine, nursing, and pharmacy and include representatives from academia and research, the U.S. Food and Drug Administration, and consumer interest groups.
Reproduced from a USP press release. USP is a non-government organization that promotes the public health by establishing state-of-the-art standards to ensure the quality of medicines and other health care technologies.
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