Guidelines Seek to Reduce Medication Errors Involving Kids

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What's to blame for the problem? According to Angood, most medications are made and packaged for adults, and most health-care facilities are built and organized around the needs of adults, not children. Also, process issues -- including miscommunication, lack of standards for labeling and packaging, and the misidentification of medications -- are at fault, he said.

Even recent innovations in technology often don't help the pediatric population. A system for computer order entry of medications implemented by Scanlon's hospital did not have weight-based dosing. "Pediatric providers were left to cobble together weight-based dosing," he said.

Similarly, bar coding of medications is sometimes not readable for children because of the range of size.

"Technology holds great promise," Scanlon said. "Unfortunately, today, that hasn't been realized and lack of explicit attention to the needs of children certainly has not helped that matter."

Perhaps the simplest solution proposed by the commission is for hospitals and health-care providers to weigh children in kilograms to arrive at the proper dosing.

"This should become the standard of recording pediatric patient weights," Angood said.

The commission is also suggesting that caregivers who prescribe medications to children be required to write out and document how they arrived at particular doses. "In other words, show the math," Angood said. "This means nurses or doctors can easily double-check the calculations of any medications administered."

The family and, if possible, the child should also be involved in the medication management process, and should be asked to repeat back any medication-related instructions, according to the guidelines.

"What's really important from the patient's or parents' perspective is not only know the child's weight [in kilograms] but also maintain a current list of a child's medications -- whether they be prescription, over-the-counter or both," Tom-Revzon said. "Also, as part of that list, it should include any allergies to medication or foods, so that even if the child doesn't end up going to the hospital, even if they go to the emergency [room] or to a different doctor, that list will help prevent potential drug interactions and duplications."

Angood added: "We can and we're obligated to do better. We really do owe it to those patients who depend on us."

More information

To learn more about the new recommendations, visit The Joint Commission.