Pediatric Medication Mix-ups Targeted

Pediatric medication errors are once again in the headlines -- and this time, the spotlight is on solutions.

The Joint Commission, a hospital accreditation group, issued new guidelines today for curbing pediatric medication errors in hospitals. The guidelines come days after the journal Pediatrics published a study showing that about 7.3% of kids at 12 U.S. children's hospitals experienced an "adverse drug event" of some sort.

That study and other events have "helped to highlight the importance of recognizing that medication safety is clearly a significant problem for children," PeterAngood, MD, vice president and chief patient safety officer for The Joint Commission, said in a news conference today.

"There are no easy answers for improving medication safety, and the fact that we're still discussing the topic demonstrates clearly," Angood said.

"We can, and we're obligated to, do better."

Preventing Hospital Pediatric Medication Errors

The new guidelines, which are partly for hospitals and partly for parents, include these tips:

• Hospitals should weigh children in kilograms, because that's how pediatric medication doses are calculated.
• Hospitals shouldn't give children any high-risk drugs until the child has been weighed.
• Doctors writing prescriptions for hospitalized children should note the calculations they made to arrive at the prescribed dose. "In other words, show the math," Angood said, so that that math can be double-checked before any medications are given.
• Parents and caregivers are encouraged to seek information and ask questions about their children's medications and to repeat instructions about those medications back to the doctor.

Pharmacist's Practical Tips for Parents

Efforts to curb hospital medication errors aren't new, but "it's about time that there was more attention paid" to that issue in children, says Catherine Tom-Revzon, PharmD, clinical pharmacy manager at New York's Children's Hospital at Montefiore.

Tom-Revzon tells WebMD that her hospital works to minimize medication errors in various ways, including using a computer system for doctors' orders, standardizing concentrations of high-risk drugs, and putting bar codes on medications to make sure the right patients get the right medications.

She also has some simple tips for parents that can make a big difference.

• Get an index card. On it, list all the medications your child takes regularly or as needed. Also list all of your child's doctors, allergies to medications or foods, past bad reactions to drugs, and the child's weight in kilograms (divide their weight in pounds by 2.2 to get their weight in kilograms.)
• Make that list now -- even if your child isn't in hospital -- and keep it with you. "Just start generating that list so that if anything were to happen, you have that information handy," says Tom-Rezvon, who points out that when a child is hospitalized, parents or caregivers may be too emotional or drained to make such a list on the spot.
• Ask questions. "Be aware that there is a pharmacist who is available to talk to them about the medications, no matter which part of the hospital they're in," says Tom-Revzon. "Ask what medications the is
  child getting, how much, how often, and why."
• Notice changes.
  If your child routinely took certain medications before getting to the hospital -- and they're not takng those drugs in the hospital -- ask about that. And if their medications in the hospital look different than what child took at home, ask about that, too. "That's how some medication errors get caught," says Tom-Revzon. "The parents are being proactive and assertive. They question, 'What are you giving my child? Why is it a different color from what I'm used to giving?'" Those differences may not be because of an error, but there's no harm in asking.
• Be patient if you get asked several different times by several
  hospital workers about your child's medications. "Sometimes it ends up
  being the nurse, doctor, and pharmacist asking them the same questions about
  their medications," says Tom-Revzon. "But really, it's a safety net to
  ensure that we get the most accurate information."

By Miranda Hitti
Reviewed by Brunilda Nazario
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