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Prescription always begins with examination of the indication and consideration of any promising alternatives to drug therapy. Age group—specific contraindications must also be observed in pediatric care Table 3. Weight-based recommended doses form the basis of prescription. These can vary significantly according to age group. Age-related formulae were the most common method used; these are known to be of poor quality 9.
For example, the weights of the six-year-old children in the study mentioned above ranged from 19 to 30 kg e In everyday clinical practice, it can also be observed that in individual cases drug doses are even established in the form of a proportion of an adult dose, with no specific estimate of weight. The very need for individual calculation of the required dose entails the possibility of calculation errors e2.
This means that familiarity with the usual dose cannot be assumed, and even tenfold dosing errors do not seem suspect and occur regularly 2. Determining the correct dose seems to be the most significant step, as this is where the highest error rate is observed 38 , e19 , e A further source of errors is the choice of preparation. As a result of the considerable variation in doses, many drugs are available in various package sizes and concentrations, and diluted forms are produced so that usable volumes can be administered.
Communication problems are also responsible for many medication errors e A complete prescription contains both a dosing formula e.
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It must also state the concentration used e. Care must also be taken with similar-sounding names e.
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If a diluted form is to be used, its exact name and preferably also instructions for producing it must be given. In most clinical situations preparing a drug solution of the required concentration and administering the necessary dose in the form of the indicated quantity is the task of a emergency medical technician. In the prospective observational study mentioned above involving simulated resuscitation events in a pediatric emergency department, the prepared syringes were collected. All the sources of error described above become even more significant when urgency is greater and the number of prescriptions is higher.
This has been demonstrated in intensive care units for adults e23 and neonates e5 , for example. In prehospital emergency care, even higher rates of dosing errors are to be expected. In addition to the emotional pressure experienced by many emergency physicians e24 , prehospital care structures have neither specialized pediatric staff nor treatment procedures optimized for pediatric patients. In hospitals, control mechanisms involving several persons with comparable skills provide a significant gain in safety; these are also absent in prehospital care.
It has also been shown that excessive fatigue among prescribing staff and nighttime hours contribute to higher error rates 38 , e25 — e Below is an outline of strategies to prevent such errors, and where possible an evaluation of their effectiveness on the basis of a comparison of the literature. All staff should have a basic knowledge of age group—specific properties of emergency drugs. Several summaries of pediatric drug therapy are available, and it seems useful to be able to refer to one of these during prehospital care Table 4.
Access to pediatric pharmacological information has been shown to increase the rate of correct dosing 7 , even if the information in question is merely a summary table 8. In specific situations it may also be useful to consult the nearest pediatric intensive care unit by telephone. Various authors insist that a child must be weighed before a drug is prescribed 39 , but this is often impossible in emergency care. It would be a useful initial step simply to attach sufficient importance to weight. The next best method is length-related estimating, which determines an average weight i.
This is therefore the method that should be used if it is impossible to weigh a child percentile curves or pediatric emergency ruler. Dosing according to ideal weight is beneficial even for obese children, as they have a lower proportional extracellular volume by weight, and this is the decisive distribution volume for the dosing of emergency drugs, analgesics, and sedatives e Once dosing recommendations and weight have been determined, the required dose can be calculated.
For example, in one pediatric hospital the use of a computer program to calculate doses halved dosing errors in prescriptions However, any other measure that can reduce the number of steps required in calculation can also reduce the error rate e For example, in a prospective study in the USA prehospital emergency physicians were asked to calculate pediatric prescriptions in a questionnaire, in a quiet, stress-free situation.
All the necessary information was always given, and only whole numbers were used. Following randomization, approximately half of the participants were allowed to consult a table for reference Table 5. It is preferable to issue prescriptions in writing whenever possible.
This can hardly be guaranteed in acute emergencies. However, at least orally, detailed and comprehensive information as well as all steps of calculation must be communicated. The recipient of the prescription should repeat these in full, as confirmation. It is expected that establishing this type of communication structure will reduce the rate of drug errors e11 , e12 , although this has not yet been researched for oral instructions. However, a lower error rate has been recorded following introduction of a written prescription form Table 6 15 — Wherever possible, the number of concentrations used should be kept to the minimum required.
If drug administration is followed by flushing, in many cases the undiluted drug solution can be used, with small syringes 1 mL syringes calibrated in 0. Syringes containing various concentrations of the same active substance should be avoided. The necessary solution concentrations must be observed precisely. Commercially preprepared, labeled syringes achieve higher levels of safety, as quality control is incorporated into the manufacturing process A disadvantage of these preprepared syringes is their limited shelf life and high cost.
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Every preprepared syringe should be labeled clearly; this is an effective check in itself e The use of color-coded stickers, as established in international standard ISO , seems to be beneficial e It has been shown that this type of labeling system can reduce at least mix-ups between drug groups In addition, syringe barcodes that can be read by smart syringe pumps seem to be particularly advisable However, it seems that this measure cannot yet be implemented in prehospital care. Below is a description of possible ways to achieve improvements in drug prescription.
These could either not be assigned to any of the points outlined above or represent groups of several subpoints. It is certainly impossible to guarantee comprehensive prehospital emergency care provided by pediatricians and pediatric nursing staff. However, it has been shown more than once that experience and training can reduce error rates. For example, training in both knowledge of pediatric drug therapy and the causes of drug errors and how to resolve them can reduce the rate of prescribing errors 4 , 19 , 20 , 24 , Error reporting systems critical incident reporting system, CIRS increase the number of errors that are reported and are the subject of constructive discussion in hospitals e20 , and although as yet there is no evidence, this can be expected to reduce errors.
However, the introduction of inspections by hospital pharmacists has been shown in itself to reduce the error rate in a neonatal intensive care unit This step was announced to staff and has clearly led to an increase in their levels of vigilance. When computer-based prescription systems are used, required doses, routes of administration, and frequencies are entered into a program, and the computer performs the calculation. A system of this kind has been shown to reduce the rate of incomplete prescriptions 21 , although in isolation it cannot reduce the rate of dangerous dosing errors 23 , e The incorporation of a database on pediatric drug therapy that includes information on dosing recommendations and a control mechanism has successfully reduced the number of dangerous dosing errors significantly 23 , 25 , In prehospital care in particular, in which some of the measures indicated above to increase prescription safety cannot be implemented due to structural factors, the pediatric emergency ruler may be useful.
Based on standardized drug preparation, the volumes to be administered according to the concentrations used are directly indicated on the pediatric emergency ruler. A majority of the cognitive effort involved in drug prescription is therefore covered by the pediatric emergency ruler, so it is not surprising that the use of a similar tool the Broselow tape has already repeatedly been shown to be beneficial in simulated resuscitation events In prehospital pediatric emergency care too, the rate of correct epinephrine doses increased almost twofold when this aid was introduced in a prospective cohort study In addition, length-related tracheal tube selection is superior to age-related selection methods Physiological normal values can also be consulted at a glance, and compliance with these values is essential to an optimum neurological outcome e Medication errors pose a substantial danger to all patients, and children in emergencies are exposed to a particularly high risk.
It would be desirable and probably also beneficial for there to be intensive, coordinated research on this subject. The same is true of all measures that lead to a reduction in the cognitive effort required for drug prescription. Conflict of interest statement. The other authors declare that no conflict of interest exists. National Center for Biotechnology Information , U. Journal List Dtsch Arztebl Int v. Published online Sep Jost Kaufmann , Dr. Author information Article notes Copyright and License information Disclaimer. Received Feb 27; Accepted Jun 5. This article has been cited by other articles in PMC.
Abstract Background Errors in drug administration are among the commonest medical errors. Method Systematic literature review. Results We found 32 original publications that concerned the evaluation of interventions for lowering error rates in the ordering of medications for children. Conclusion Children in medical emergency situations are at significant risk for medication errors.
Method This article is based on a systematic review of the literature, using a search of PubMed Table 1. Table 1 PubMed research database existing since , last accessed in May Outpatient or elective care, self-medication of which: Open in a separate window. Results The authors identified 22 clinical studies on the prevention of medication errors in pediatric care. Table 2 Measures to improve the quality of drug prescriptions for children and evidence of their effects. Analysis of the drug prescribing process and sources of error Determining the indication Prescription always begins with examination of the indication and consideration of any promising alternatives to drug therapy.
Table 3 Examples of age group—specific contraindications for drugs that are unproblematic in adults. Drug Age group—specific property Acetylsalicylic acid In those under 12 years old, only to be used with the strictest indication, Reye syndrome e34 Metoclopramide May cause extrapyramidal disorders in those under 12 years old e35 Promethazine May increase the risk of sudden infant death promethazine or other antihistamines with sedative effect e Determining recommended dose Weight-based recommended doses form the basis of prescription.
Dose calculation, preparation The very need for individual calculation of the required dose entails the possibility of calculation errors e2. Compiling and issuing prescriptions Communication problems are also responsible for many medication errors e Preparing and administering prescribed drugs In most clinical situations preparing a drug solution of the required concentration and administering the necessary dose in the form of the indicated quantity is the task of a emergency medical technician.
The effect of care context on error rate All the sources of error described above become even more significant when urgency is greater and the number of prescriptions is higher. Interventions for improving drug prescriptions Below is an outline of strategies to prevent such errors, and where possible an evaluation of their effectiveness on the basis of a comparison of the literature.
Determining indication and dosing recommendations All staff should have a basic knowledge of age group—specific properties of emergency drugs. Table 4 Examples of short summaries on pediatric drug therapy in German. Author, year Title, publisher Wigger et al. Determining weight Various authors insist that a child must be weighed before a drug is prescribed 39 , but this is often impossible in emergency care. Dose calculation, preparation Once dosing recommendations and weight have been determined, the required dose can be calculated.
Table 5 Reference adaptation of Bernius emergency dosing card Issuing prescriptions It is preferable to issue prescriptions in writing whenever possible. Table 6 Presciption form after Kozer Preparing and administering prescribed drugs Wherever possible, the number of concentrations used should be kept to the minimum required. Additional interventions for improving drug prescriptions Below is a description of possible ways to achieve improvements in drug prescription. Staff training, observation and reporting systems It is certainly impossible to guarantee comprehensive prehospital emergency care provided by pediatricians and pediatric nursing staff.
Electronic prescription systems When computer-based prescription systems are used, required doses, routes of administration, and frequencies are entered into a program, and the computer performs the calculation. Conclusion Medication errors pose a substantial danger to all patients, and children in emergencies are exposed to a particularly high risk. Key Messages Staff should receive regular training in the causes and prevention of medication errors and knowledge of pediatric drug therapy.
Regular inspection of prescriptions also significantly improves their quality. Appropriate methods should be used to estimate weight. Doses should be calculated using electronic aids e. Access to data on pediatric drug therapy age group— specific doses, drug preparation, and contraindications must be guaranteed at all times. The lowest possible number of drug concentrations should be used; wherever possible, dilution should be avoided e. Syringes must be labeled as systematically as possible e.
Medication Errors in Pediatric Emergencies
Wherever possible, prescriptions should be written on structured prescription forms. If prescriptions are issued orally, a communication structure must be established whereby a structured, complete request is made and repeated in full by its recipient as confirmation. Footnotes Conflict of interest statement Dr. Building a Safer Health System. National Academy Press; To Err is Human. Large errors in the dosing of medications for children. N Engl J Med. Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department.
Medication errors in pediatric inpatients: Medication dosing errors in pediatric patients treated by emergency medical services. Medication errors in paediatric care: Qual Saf Health Care. Development and impact of a computerized pediatric antiinfective decision support program. Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.
Effect of an intervention standardization system on pediatric dosing and equipment size determination: Arch Pediatr Adolesc Med.
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