I recently had breakfast with a close friend who had suffered a heart attack at far too early of an age a few months ago. Luckily, he was able to get medical care just in time, received great treatment, and is now doing well and on the road to recovery. Thanks to the level of knowledge, experience, and sophistication that surrounds the treatment of heart issues, my friend was truly able to dodge a bullet.
Unfortunately, when children are in emergency situations, it can be a very different scenario, particularly when it comes to ordering and administering medications. Unlike my friend, children in emergency situations often find themselves in acute care facilities that lack the requisite pediatric expertise and training to safely administer emergency medications. Far too many times, pediatric patients don’t get the chance to dodge this bullet.
The American Academy of Pediatrics (AAP) recently published a paper on pediatric medication safety. Their findings are shocking. Medication error rates in pediatric patients were found to be three times higher than in adults. One study revealed that error rates ranged from 10 to 31 percent. Another study of rural emergency departments (EDs) in northern California found an error rate of 39 percent. Let the tragic enormity of that fact sink in for just a moment. In low-resource medical settings, 39 out of every 100 children suffer a medication error during an emergency!
The challenge of pediatric medication dosing
How can this happen, when care treatments are advancing so rapidly, and our knowledge of proper medical care is expanding exponentially? Sadly, there are a number of challenging reasons.
There are over 5,500 hospitals in the U. S., but only about 200 are pediatric hospitals. As a result, nine out of 10 children in an emergency situation are treated in non-pediatric, community hospitals. However, in these facilities, pediatric emergencies make up only a small percentage of day-to-day cases. Clinicians just don’t deal with many pediatric emergencies. They simply don’t have the same experience as they do with adults.
Unlike with adults, emergency pediatric dosing is primarily weight based. As the AAP report points out, there is no fixed dose for kids. This complicates the process. Doctors and nurses must rely on patient weight to establish proper dosing, and must perform math calculations to determine the appropriate dosage and dilution – often right at the point of care. Additionally, pharmacist support and IT systems often lack pediatric safety features. And all this takes place in the chaos of an ED.
ED Directors, nurses, physicians, pharmacists, quality officers, and senior leaders in health care organizations are always working hard to increase pediatric medication safety. Here are five suggestions based on our experience at eBroselow and echoed in the AAP report that can help us all reach that goal.
More effective safety procedures
Many EDs are dealing with the need to ensure medication dosing safety by instituting special procedures – sometimes called Red Rules. These often involve independent double checks (IDC) of specific medications prior to administration. While an IDC can take up to 20 minutes, the AAP report notes that the implementation of a two-provider check process for high-alert medications can positively help reduce administration errors.
While this is an important first step, the reality is that humans make math errors three percent of the time. Under stressful situations, error rates jump to 25 percent and double-check errors occur 10 percent of the time. We need to continue to explore ways to use technology to make these double checks even more effective.
Increased knowledge support
The AAP report notes that many medications are prepared and dispensed in the ED without being verified by pharmacists. The report references a study that shows that more than two thirds of pharmacists provide eight hours of coverage on weekdays but less than half have the same coverage on weekends. Many rural and community hospitals lack a high level of pharmacist support.
Unfortunately, financial constraints often prevent hospitals and other ER facilities from hiring more pharmacists. In the 1980’s, Dr. James Broselow invented the Broselow Tape to address the reality that pharmacists aren’t always around to answer questions. The color-coded tape measure relates a child’s height to his or her weight to provide medical instructions including medication dosages. The tape provided a way to guide clinicians to deliver proper dosing and it is still in use in many facilities today.
The issues the Broselow Tape addressed 30 years ago are still relevant today despite the billions of dollars of investment in technology. EDs must continue to seek ways to access medication knowledge in the absence of experienced pharmacists.
Standardized concentrations and better access to reference materials
One of the major causes of pediatric medication dosing errors is lack of experience administering various medications to small children. The AAP report urges standardizing the concentrations available for a given drug, having readily available medication reference materials, and having pharmacists and ED care providers work together as a team.
Many CPOE solutions provide such reference material, but clinicians must wade through volumes of information to get to pertinent answers to the specific questions they face. In the time-constrained and chaotic ED environment, nurses and physicians need to be able to quickly access the appropriate reference data they need.
Expanded use of technology
Electronic Health Records (EHRs) have proven to be a valuable addition to the safe care of patients. In terms of medication, they promised to be powerful, all-knowing computer systems that would solve problems with dosing and administration. But this hasn’t been the case. The AAP report points out that computerized physician order entry (CPOE) and clinical decision support (CDS) with electronic prescribing has helped, but they haven’t eliminated medication errors. This is because they fail to address unique pediatric dosing issues like weight conversion requirements from pounds to kilograms.
ED leaders should look beyond relying totally on their EHR for technology solutions. It’s time to consider complementary solutions that can provide enormous value in assuring proper medication administration for children.
The lack of familiarity and experience with pediatric emergencies should be countered with more effective training for clinicians who face these situations. The AAP report states that pediatric medication safety training programs vary widely in medical, nursing and pharmacy schools.
Leaders in pediatric emergency care recommend that a standard curriculum on pediatric medication safety should be developed for all clinicians who deal with children in emergency settings. The training should include discussions of common medication errors in children, improved tools to minimize or eliminate errors, and the effects of developmental differences in pediatric patients.
Our children are at significant risk from improper medication dosing and administration errors. We must all work together as an industry to develop and implement solutions that make these errors a thing of the past and ensure that our children receive the proper care at their most vulnerable times.
 Pediatric Medication Safety in the Emergency Department, Lee Benjamin, Karen Frush, Kathy Shaw, Joan E. Shook, Sally K. Snow, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Emergency Medicine Committee, Pediatrics Mar 2018, 141 (3) e20174066, DOI: 10.1542/peds.2017-4066