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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," Peter Angood, 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.

"Children are not just small adults," says Matthew Scanlon, MD,
assistant professor of pediatrics and critical care medicine at the Medical
College of Wisconsin and a member of the Joint Commission group that wrote
today's guidelines. "This is another important step in increasing awareness
around the unique needs of children."

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

  • 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."

Lastly, it wouldn't hurt to make an index card with a similar list for
yourself, just in case you are ever hospitalized.

By Miranda Hitti
Reviewed by Brunilda Nazario
©2005-2008 WebMD, LLC. All rights reserved

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