Systematic Steps to Diminish Multi-Fold Medication Errors in Neonates

Pinheiro, Joaquim; Mitchell, Amy L.; Lesar, Timothy S.

doi:10.5863/1551-6776-8.4.266

Cited by 5 publications

(5 citation statements)

References 19 publications

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“…Many health care facilities have implemented standards of practice to reduce the incidence of the potentially lethal errors described previously [38]. Concentrated solutions of potassium and sodium have been removed from patient care areas and are stored, prepared, and dispensed in the pharmacy.…”

Section: Solutions To Errorsmentioning

confidence: 99%

Medication errors in pediatrics—the octopus evading defeat

Sullivan

Buchino

2004

Journal of Surgical Oncology

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Medication errors have come to the forefront in healthcare and oversight organizations as well as to the public over the past several years. There has been an increasing focus on this area of patient care requiring more intensive evaluation and intervention to prevent these errors. Although it is difficult to ascertain the true occurrence of medication errors, they may occur as frequently as once in every 20 orders. Children are at higher risk for medication errors and adverse drug events for numerous reasons. Not only is there great variability in weight and body surface area in this population, there is also significant differences in the pharmacokinetics and pharmacodynamics of many medications when compared to adults. In addition, our knowledge of pharmacogenetics and phenotypic ontogeny must be applied. Sources of medication errors are identified, and specific examples and solutions to improve medication use in children are provided. It is critical to have 1) personnel trained in pediatrics to prescribe, prepare, dispense and administer medications, 2) a quality review system in place to review drug use and medication errors, and 3) to implement computerized physician order entry with decision support and other tools in the next decade to improve pharmacologic therapy for pediatric patients.

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Section: Solutions To Errorsmentioning

confidence: 99%

Medication errors in pediatrics—the octopus evading defeat

Sullivan

Buchino

2004

Journal of Surgical Oncology

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“…The traditional variable concentration approach is subject to errors in the calculation of the solution drug concentration, preparation of the individual infusion or the setting of the solution infusion rate (8)(9)(10). Using a small number of centrally prepared SCs reduces the potential for error in solution preparation and the risk of contamination from multiple-use medication vials.…”

mentioning

confidence: 99%

Standard concentrations of high-alert drug infusions across paediatric acute care

Irwin¹,

Vaillancourt²,

Dalgleish³

et al. 2008

Paediatrics &Amp; Child Health

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“…6 The process of ordering, preparing, and administering continuous medication infusions offers several opportunities for error. 4,[7][8][9] Providing the correct weight-adjusted dose (at an acceptable rate, concentration, and volume) usually requires a multivariable calculation; moreover, a new calculation must be performed whenever the dose is changed. The need for individualized concentrations makes drip preparation a high-frequency and time-consuming task for the pharmacy.…”

mentioning

confidence: 99%

Standard Drug Concentrations and Smart-Pump Technology Reduce Continuous-Medication-Infusion Errors in Pediatric Patients

et al. 2005

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ABSTRACT. Objective. To determine if combining standard drug concentrations with "smart-pump" technology reduces reported medication-infusion errors. Design. Preintervention and postintervention comparison of reported medication errors related to infusion therapies during the calendar years 2002 and 2003.Setting. A 242-bed university-affiliated tertiary pediatric hospital.Intervention. Change in continuous-medication-infusion process, comprising the adoption of (1) standard drug concentrations, (2) "smart" syringe pumps, and (3) human-engineered medication labels. Main Outcome Measures. Comparison of reported continuous-medication-infusion errors before and after the intervention.Results. The number of reported errors dropped by 73% for an absolute risk reduction of 3.1 to 0.8 per 1000 doses. Preparation errors that occurred in the pharmacy decreased from 0.66 to 0.16 per 1000 doses; the number of 10-fold errors in dosage decreased from 0.41 to 0.08 per 1000 doses.Conclusions. The use of standard drug concentrations, smart syringe pumps, and user-friendly labels reduces reported errors associated with continuous medication infusions. Standard drug concentrations can be chosen to allow most neonates to receive needed medications without concerns related to excess fluid administration. M edication errors are a major source of potential and actual harm in pediatric patients. [1][2][3] Pediatric patients are at greater risk for medication error than adult patients because of the need for weight-based dosing and individualized dose calculation for most medications. Effective communication about symptoms and elicitation of pertinent clinical findings is often difficult in children. 2,4 Medical complexity and the need for multiple medications places hospitalized children at an even greater risk; nowhere is this more evident than in intensive care units. [2][3][4][5] Continuous medication infusions are a category of medications delivered to hospitalized patients that often include "high-alert" medications. As defined by the Institute of Safe Medication Practice, highalert medications are drugs that bear a heightened risk of causing significant patient harm when used in error and may lead to devastating complications for patients. 6 The process of ordering, preparing, and administering continuous medication infusions offers several opportunities for error. 4,[7][8][9] Providing the correct weight-adjusted dose (at an acceptable rate, concentration, and volume) usually requires a multivariable calculation; moreover, a new calculation must be performed whenever the dose is changed. The need for individualized concentrations makes drip preparation a high-frequency and time-consuming task for the pharmacy. The appropriate information must be entered correctly into the pump initially and when changes are made.Several common practices influence the likelihood of continuous-medication-infusion errors. The "rule of 6" is a calculation aid that was developed originally to facilitate rapid dose calculation and drip preparation in ...

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Systematic Steps to Diminish Multi-Fold Medication Errors in Neonates

Cited by 5 publications

References 19 publications

Medication errors in pediatrics—the octopus evading defeat

Medication errors in pediatrics—the octopus evading defeat

Standard concentrations of high-alert drug infusions across paediatric acute care

Standard Drug Concentrations and Smart-Pump Technology Reduce Continuous-Medication-Infusion Errors in Pediatric Patients

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