The medication error in which actor Dennis Quaid's newborn twins were mistakenly given 1,000 times the prescribed dose of the blood-thinning drug Heparin made headlines several months ago. According to Stu Levine, of the Institute for Safe Medication Practices, “research indicates the potential for adverse drug events amongst hospitalized pediatric patients is three times as high as among adults.” One of the main reasons for this is that the medications are formulated and packaged for adults, thus needing to be prepared in different volumes and concentration for kids. Altering the dose so it is correct for children requires calculations that have the potential for error. The Joint Commission (USA's predominant health care accrediting organization) recently issued new guidelines to address pediatric medication errors in hospitals. It points out in its findings that most health care settings are geared toward adults and lack staff trained in pediatrics. The new guidelines are meant to raise awareness for both medical personnel and parents who have children with unique medical needs. These children are not just small adults. Since dosing is based on weight, one recommendation is all pediatric patients should be weighed in kilograms at the time of admission or within four hours if admitted as an emergency. No high-risk drugs should be given until the child is weighed. Since pediatric medication doses are calculated by kilograms, this should be the standard for medical records and staff communications. When doctors write out medication orders, they should include the calculations they used to get to the prescribed dose so it may be double-checked by a nurse or pharmacist. They also recommend that concentrated adult medications be kept away from pediatric units and that all practitioners be routinely provided continuing education on the proper dosing and dispensing of pediatric medications. When a child is hospitalized, it is usually a stressful time for most parents. That being said, this is not a time to let emotions cause you to let down your guard. To help prevent medication errors, organize these tips to partner with the hospital staff: Prepare ahead by creating a list of all current medications your child is taking. Note known allergies and past adverse drug reactions. Keep this list accessible should an emergency arise. Know your child's weight in kilograms by dividing his or her weight in pounds by 2.2. There should be a pharmacist with pediatric expertise on call for the hospital. Ask to meet to have medication questions explained. If various personnel (doctors, nurses, pharmacists) are asking you about medication history, be patient with the repeated questions. In a teaching hospital, this could even be multiplied but the more people cross-checking, the better chance of avoiding errors. Pay attention to the drugs your child is being given. Ask what they are for and question if they look different then what he/she has been taking. Check your child's hospital ID band to be sure all information is accurate. Be sure the staff also checks it before giving medications. Pay close attention to medication discharge instructions including proper administration and possible side effects. Repeat back what you understand to be the directions to the discharging medical staffer. Take an active role in your child's medical care. - Albany Times Union __
