Medication Errors: Neonates, Infants and Children Are the Most Vulnerable!

Abstract

Medical errors continue to plague the increasingly complex inpatient medical care system. Pediatric patient populations continueto be those most vulnerable to serious and sometimes fatal adverse drug events. Studies have shown that up to 93% of medication errors in children might have been prevented by computerized physician order entry (CPOE) and unit-based clinical pharmacists.1–4 A recent study reported that adverse drug event (ADE) rates in hospitalized children are substantially higher (15.7 per 1000 patient-days) than previously described.5 Professional organizations have provided detailed guidelines for preventing medication errors in pediatrics.6–8 With practice guidelines, prevention strategies and the benefits of unit based clinical pharmacists, why do these errors continue to happen? The following issues still need to be addressed by organizations treating pediatric patients, pharmaceutical manufacturers, medical software vendors and technology innovators:On April 11, 2008, The Joint Commission published a “Sentinel Event Alert” on preventing pediatric medication errors.10 This alert outlines pediatric specific risk reduction strategies for reducing medication errors: 1) Standardize and identify medications effectively, as well as the processes for drug administration. 2) Ensure full pharmacy oversight as well as the involvement of other appropriate staff-in the verifying, dispensing and administering of both neonatal and pediatric medications. 3) Use technology judiciously.Other Joint Commission suggested actions are also included in this document. Although most, if not all of these recommendations, are in place in the nation's Children's Hospitals, they are not common in hospitals where infants and children are only a small portion of the patient population. All hospitals that treat any infants or children should make every effort to make their medication—related systems and processes safe for the most vulnerable patients. Getting to zero errors will require the constant vigil of all healthcare professionals. CPOE, barcoding, the use of robotics and ADCs are tools that can help but they need careful application in the pediatric arena.