Preventable Pediatric Medication Errors

Preventable Pediatric Medication Errors
It’s bad enough for parent and child when a child requires hospitalization and possibly surgical intervention, without additional, preventable risks created by the hospital. Unfortunately, the risks you have to worry most about are hospital care-associated infections (HAIs) or “nosocomial” infections, which are the most common and deadly complication of hospitalization, and hospital medication errors and/or adverse drug events. A Joint Commission on the Accreditation of Hospitals Organization study found that more than 10% of pediatric inpatients suffered adverse drug events. Pediatric med errors were most often caused by lack of knowledge/training, failure to follow procedures for medication administration, and communication errors, followed by calculation mistakes, computer entry errors, inadequate/failure in patient monitoring, improper use of pumps, and documentation errors.

Because the dosing of most drugs is based on weight, there is the potential for a 300-fold dosing error for pediatric or neonatal patients. This kind of error can be deadly. Most of us have heard about med errors. In 2007, movie star Dennis Quaid’s two-week-old twins nearly died after they were mistakenly given massive overdoses of the blood thinner Heparin, an adult medication, rather than the pediatric version. The infants got a thousand times the necessary dose, not just once, but several times, and almost died. Three infants in Indiana did die of the same type of error with heparin.

Although the research does not state this fact, the truth is that the shortage of registered nurses which results in short staffing, or lack of adequately trained staff, is the primary underlying cause of both hospital-acquired infections and adverse drug events.

For years, there has been a worldwide shortage of registered nurses [RNs]. Many hospitals simply do not have enough RNs to provide adequate, error-free care. They are “short-staffed.” RNs supervise lesser-licensed nursing staff, but without adequate staffing levels, they are unable to do all of the required tasks for each patient.

Many hospitals have a “turn-about” float policy, as well. What this means is that when one unit or area of the hospital is too far below staffing requirements for safe care, the hospital requires one of the RNs from an area with more nurses [which may also be short-staffed, but not as badly] to “float” or go to work on the most poorly staffed area – and the RN these hospitals choose to float to another unit is the one whose turn is next just because it’s that RN’s turn, and not because the RN is the most qualified for the receiving unit. This means that the float RN on your unit might have no pediatric experience.

Because of the difference between pediatric and adult medications and dosages, this lack of experience can be a critical factor.

Many people think that one RN is just as good as another, regardless of where they work or the experience they have. This is not true. The ability of the RN to recognize and act on sometimes minute changes in the patient’s status is what allows an experienced RN to frequently save a patient’s life. Further, RNs acquire specialized skills in their own areas of expertise, skills that enable them to tell when a patient is “going bad.” A Labor & Delivery RN may be excellent dealing with laboring patients and their newborns, but totally unprepared to deal with trauma patients in the ER or pediatric patients on the floor.

One of the most important things about pediatric RNs is their knowledge and experience with small patients whose medications are different from adult medications. One thing they know for sure is that the prepackaged medications are packaged at adult dosage, and frequently at higher strengths for adult dosage dilution. A good pediatric nurse recognizes a wrong medication when she sees it, because she has seen so much pediatric medication. The two medications that were confused for the Quaid twins were in similar bottles, with two different colors of blue labels. This is not an error an experienced pediatric nurse should make. She might not recognize the adult medication, but she should be aware of the appropriate color for the pediatric meds with which she is very familiar. On the other hand, a med-surg RN who is used to working with adult patients might not even know that the pedi med is different. She might just accept what was given her, and administer it.

Another important factor is that pediatric symptoms can be very different from adult symptoms, vague, unrecognized by the patient and family, and not reported appropriately or in a timely manner. Pediatric nurses require special training to provide adequate care to their pediatric patients.

These are just a few of the factors that increase your child’s risk of injury, disability, or death as a direct result of hospital errors. See the related articles “Preventable Pediatric Nursing Care Errors” and “Risk Management for Pediatric Patients” for additional information on this problem, and for some ways you can prevent such errors and minimize your child’s risks.

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