Medication Errors in Pediatric Emergency Care: Developing a National Standard?

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SEE RELATED ARTICLE, P. 361.

[Ann Emerg Med. 2007;50:369-370.]

The magnitude of the problem of medication errors was recently addressed in a report from the Institute of Medicine (IOM) entitled Preventing Medication Errors.¹ This report stated that “medication errors are surprisingly common and costly to the nation” and noted that, in hospitals, errors are common in every step of the medication process. The report suggests that, when combining all types of medication errors, a hospitalized patient may be subjected to more than 1 medication error per day.

Studies have shown that medication error rates in hospitalized children are even more common than among hospitalized adults. Of further concern is the likelihood that the risk for medication errors in pediatric patients in the emergency department (ED) is higher than for hospitalized children, though few studies have been published describing the actual incidence of medication errors in the pediatric emergency setting.

This article is one of the first to describe the incidence of medication errors among children treated in rural EDs, and for this reason it represents an important contribution to the literature.² However, the description is hindered by several factors that pose barriers for all studies of medication errors in pediatrics: the lack of tools or instruments available for use in identifying errors that may occur throughout the medication therapy process and the fact that there are no national standard dosing recommendations for pediatric medications. Indeed, as the authors note, there is no single, standardized approach to retrospectively measure the incidence of medication errors among pediatric patients.

The authors of this study developed an instrument to identify and categorize medication errors by using retrospective medical record review, modifying a previously published instrument to make it more applicable to review of ED records. Then, because there are no standard national recommendations for dosing ranges of pediatric medications used in the ED, the authors established guidelines that allowed for classification of what constituted a “wrong dose” within a categorization of the most common medications prescribed in the pediatric ED. Pediatric pharmacists and physicians within the authors’ institution defined these guidelines by generating acceptable ranges (upper and lower limits) that differ from ranges previously published, as they describe in their Table 2.

The instrument was used to identify errors in 4 of 5 stages of medication therapy: prescription, transcription, dispensing, and administration. Certainly, errors in prescription can be measured by comparing the dose that is documented in the record to an acceptable range. However, without a national standard dosing range, it remains difficult to ascertain whether a drug dose is an “error.” If one “acceptable dosing range” is used in this study, and different “acceptable dosing ranges” are used in subsequent studies, we are left with several challenges: an inability to compare study results, poor understanding of the potential magnitude of the problem of medication error in pediatric emergency care, and limited opportunities to develop improvement strategies.

Additional problems exist when one tries to understand the medication errors related to other stages of medication therapy, such as transcription, dispensing, and administration. Although medical record review can be used to determine the dose prescribed by the physician, nurses must convert the dose (in mg) written by the physician to a volume (mL) of medicine to be drawn up (dispensed) and administered, depending on the formulation (concentration) of drug available to them. Generally, nurses do not document the converted dose (volume) and concentration of medication that was dispensed and administered. Therefore, how can one accurately measure medication errors in these stages, other than by direct observation?

The IOM report on preventing medication errors outlined a comprehensive approach to decreasing medication errors. Included among the recommendations was this directive: “Reducing preventable ADEs [adverse drug events] will demand the attention and active involvement of everyone involved. The federal government should, for example, pay for and coordinate a broad research effort aimed at learning more about preventing medication errors.” Similarly, the IOM report on the future of emergency care, Emergency Care for Children, outlined recommendations to improve the safety of children receiving care in the ED.³ Authors of this report also recommended that the federal government (Department of Health and Human Services and National Highway Traffic Safety Administration) fund the development of medication dosage guidelines, formulations, labeling, and administration techniques for the emergency care setting to maximize effectiveness and safety for children.

Perhaps it is time to convene a national consensus meeting of experts in the pediatric emergency care medication process to establish some standard guidelines necessary for further research in this critically important area. The establishment of recommended dosing ranges for medications used in the pediatric emergency setting and a standard approach to measuring pediatric medication errors would allow us to more accurately identify and quantify errors and, more important, to define better strategies to prevent harm to children from medications used in emergency care.

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References 

1. Institute of Medicine Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2006;
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2. Marcin JP, Dharmar M, Cho M, et al. Medication errors among acutely ill and injured children treated in rural emergency departments. Ann Emerg Med. 2007;50:361–367
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3. Institute of Medicine Committee on the Future of Emergency Care in the United States Health System. Emergency Care for Children: Growing Pains. Washington, DC: National Academies Press; 2006;
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