USP Quality Review

The USP Center for the Advancement of Patient Safety (USP CAPS) identified numerous medication errors in the age-specific population of birth to 16 years*. Reports of these medication errors received through the USP Medication Errors Reporting Program were presented to the USP Safe Medication Use and Pediatric Expert Committees for review and evaluation. As a result of their evaluation, major recommendations for avoiding medication errors in the pediatric population were published by USP.

Pediatric errors were also identified and evaluated in the Summary of Information Submitted to MEDMARX® in the Year 2001. MEDMARX is USP's anonymous, Internet-accessible medication error tracking and trending tool for hospitals. The current 550-plus participating facilities have recorded more than 400,000 medication errors to the MEDMARX database. Data from the 2001 MEDMARX summary report concluded that the top three types of medication errors and the medications associated with those errors identified in pediatric patients were "Improper dose/ quantity" (Fat Emulsion, Potassium Chloride, and Morphine), "Omission" (Albuterol, Gentamicin, and Cefazolin), and "Wrong time" (Gentamicin, Ampicillin, and Vancomycin) (Table 1).

Pediatric healthcare is especially challenging because healthcare practitioners must consider a child's age, weight, medication dosing frequencies, and numerous other factors to ensure the safety of the pediatric patient. The MEDMARX report findings also included

• Almost 52% of pediatric medication errors occurred during the administration of the medication
• Nearly 6% of medication errors in pediatric populations caused patient harm
• Not following the procedure or protocol resulted in 26% of pediatric medication errors

A Sampling of Case Reports Presented to the Expert Committees:

CASE REPORT 1 A premature 1.4-kg infant was being treated with aminophylline for episodes of apnea. A loading dose of 7.4 mg was ordered. A nurse drew up 7.4 mL (185 mg) instead of 0.3 mL (7.4 mg) and administered the dose to the infant. The infant's condition deteriorated, requiring intubation and ventilator support. The infant expired within 36 hours of the incident. Aminophylline 250 mg/10 mL is a floor stock item and the nursing staff routinely prepares their own doses for administration. The pharmacy prepares some, but not all, of the parenteral doses in prefilled syringes. As a result of this medication error, numerous policies and procedures were revised, including

• Requiring a double check by a second nurse of calculations and syringe volume drawn in the Neonatal Intensive Care Unit (NICU)
• Requiring a double check of dose to be administered
• Requesting additional pharmacy assistance for preparation of prefilled syringes
• Developing calculation worksheets
• Reevaluating the list of floor stock medications stored in NICU

CASE REPORT 3 A physician wrote an order for pain control for an eight-year-old male with a fractured femur. The order read "Morphine 2-3 mg IV every 2-3 hours as needed for pain." The order was transcribed by hand to the Medication Administration Record as "Morphine 2 3 mg..." A nurse on the late shift drew up a dose of 23 mg of morphine, had the medication checked by another nurse on the shift (2.3 mL of a 10-mg/mL vial of morphine), and administered the dose intravenously. The patient fully recovered following resuscitation and Narcan administration and was discharged three days postincident. The root cause analysis found, first, that the physician should not write for doses in ranges. Second, the nurse should have been alert to the fact that she was withdrawing from multiple vials for a pediatric dose. Third, the nurse checking the dose verified only that the syringe contained 23 mg of morphine and did not check the dose against the ordered dose. Fourth, the nurse that transcribed the order left out the hyphen or dash separating the doses in the range, which lead to the misinterpretation. Fifth, the nurse had little experience and was not familiar with morphine dosing in pediatric patients.

CASE REPORT 4 A seven-week-old infant diagnosed with acid reflux was prescribed cimetidine 0.5-mL three times a day. The technician gave the parents a 10-mL syringe and pointed to the 5-mL mark to indicate the correct dosage. The mother, who knew the dose was 0.5 mL, questioned the technician and was told that drawing the medication up to the 5 mark on the syringe was a 0.5-mL dose. The baby was given four 5-mL doses. The baby became very drowsy, vomited, and had loose stools. The infant was taken to the emergency room but did not require treatment.

Medication errors in the pediatric population affect patients, parents, and practitioners. They result from

• Miscalculations and misinterpretation of drug dosages
• Inappropriate measuring devices for pediatric products
• Nonadherence to procedures and protocols
• Nonadherence to double checking
• Inexperienced and insufficient hospital staff
• Inappropriate counseling