Preventing Medication Mistakes

Family Magazine April 1 - May 15 issue.  Re-printed with permission by U.S. Pharmacopeia

Pediatric medication errors can often occur in the hospital when a decimal point is misplaced in a medication dose or when there is an incorrect conversion in the child's weight from pounds to kilograms. For this reason, the United States Pharmacopeia (USP), a nongovernment organization that establishes quality standards for medicines, recently announced recommendations for preventing medication errors when children are in the hospital and at home. 

USP's Center for the Advancement of Patient Safety (CAPS) felt the recommendations were necessary after analyzing medication error data reported in 2001 by Medmarx, a national reporting database operated by USP. Of the 105,603 errors documented by Medmarx, 3,361 errors, or 3.2 percent of total errors, involved pediatric populations (birth to 16 years). Although the majority of errors were corrected before causing harm to the patient, 5.7 percent of total errors did result in patient injury. Two errors resulted in a patient's death. 

“Medications for children are usually dosed by weight in kilograms, which means that adult dosages are often diluted based on weight conversions from pounds to kilograms,” said Diane Cousins, R.Ph., vice president of CAPS at USP. “Because weight calculations are recognized as a frequent problem in pediatric medication dosing, parents can help prevent errors by knowing their child's weight in kilograms and re-confirming with their child's doctor that their child is receiving the proper dosage.” 

“Parents should also inform the health care provider of any and all allergies their child has, and make sure the provider lists them on their child's medical chart,” added Cousins. “In the home, it is essential that parents use their senses to identify their child's medication by size, shape, color, smell, and sight. If their child is old enough, parents can also teach the child to use his or her senses as well.” 

Tips for Parents:

Health care practitioners must consider a child's age, weight, medication dosing frequencies, and other factors to help ensure the safety of young patients. While medication errors can happen to any patient at any age, the consequences can be far more devastating when children are involved. With this in mind, USP offers parents these tips to help prevent medication errors from happening to their children: 

• When your child is admitted to the hospital, give the doctor an up-to-date list of all medicines (prescription and over-the-counter) and dietary supplements that your child is taking. This will help minimize medication errors and prevent drug interactions while your child is in the hospital. 
• Make sure your child's doctor is aware of any allergies your child may have. For life-threatening allergies, be sure that your child wears a MedicAlert bracelet at all times.
• Medications administered to children are based on the child's weight in kilograms. In order to prepare appropriate dosages of medicines, your child's weight in pounds must be divided by 2.2 to convert the weight into kilograms. (Thus, a child who weighs 35 pounds would weigh 15.9 kilograms.) Be aware of this calculation and/or your child's weight in kilograms, and reconfirm the correct dosage with your child's doctor if you have concerns.
• Be sure that you get verbal and written information about your child's medications, the common side effects, and know of any adverse events that should be reported to your child's doctor.
• Pay close attention to how your child is feeling while in the hospital. Notify the doctor immediately if you notice any negative side effects from the administered medications, such as sudden difficulty in swallowing or breathing. 
• If your child receives a liquid medication to take after release from the hospital, be sure you get an appropriate measuring device and instructions to ensure proper medication doses. 
• In case of an emergency, be sure that your child's school has a list of any medical conditions or allergies your child may have.