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Decreasing Medication Errors in Pediatric Subspecialty Clinics Eve L. Taylor, RN, BSN, CPHRM, CPHQ
Nemours Quality and Safety Department
OBJECTIVES
Medication errors in pediatric subspecialty clinics can cause morbidity and mortality in complex pediatric patients (1). A total of 15% of pediatric prescriptions have potential dosing errors (2). Our objective is to identify the most common causes of medication errors, as well as introduce methods to mitigate and prevent errors. Our focus is on process improvement, not persons. Nemours has had an electronic medical record and computerized order entry for 15 years, so legibility is not relevant to this study. According to Leapfrog, computerized physician order entry (CPOE) and barcoding may reduce medication errors by 50% (3).
ERRORS BY CLASS AND FREQUENCY
UNORDERED MED UNDER DOSAGE OVER DOSAGE OTHER MEDICATION RELATED
METHODS
We reviewed several scholarly articles related to pediatric medication errors and queried our event database for retrospective self-reported medication errors (including near-miss events) in the outpatient subspecialty pediatric clinic for a period of 7 years (2004-2011).
ORDERED, NOT DONE OMITTED DOSE LABELING ISSUE
RESULTS
The two most frequent events that affected patients were adverse drug reaction related to anaphylaxis that was previously unknown for the patient and medication “other” events.
INCORRECT TIME
Adverse drug reactions are difficult to prevent but can be managed with appropriate protocols or countermeasures, such as preparation of drugs to counteract the effect of anaphylaxis before giving any new high alert medication and patient observation for 1 hour with vital signs every 15 minutes. Preemptive development of procedural consents that educate families about the possibilities of events and the related signs and symptoms is suggested. A physician-led informed consent process is critical for the patient and their family.
Medication “other” events included delivery issues from the pharmacy and any signs of off-color or broken seals, etc. These events may have had an impact on the timing of medication but did not reach or harm a patient. The next most frequent type of event was incorrect strength or concentration, which can be caused by weights that are not correct (weight should be in kilograms) or outside community pharmacies that do not specialize in pediatric dosing (4). Pharmacies are many times unaware that the pediatric dose of the drug cannot safely be attained without using an oral syringe that shows the pediatric dose in milliliters .
Family education and syringes marked for the proper dosing in the clinics or from pharmacies and sent home with the families help mitigate these types of events. Outpatient settings need to have rigorous sample medication auditing processes for expired/recalled medications, as there is usually no pharmacist on-site. Documentation of quantity, lot number, and expiration dates of the samples is a minimum requirement. All patients receiving samples require documentation of lot number and quantity recorded in the electronic medical record (EMR). Auditing this process decreases the likelihood of patients receiving expired medication and allows the ability to contact patients if there is a recall.
INCORRECT STRENGTH OR CONCENTRATION INCORRECT ROUTE INCORRECT PATIENT INCORRECT NARCOTIC PROCESS INCORRECT FREQUENCY INCORRECT DRUG EXPIRED MEDICATION COMPUTER ENTRY INCORRECT ADVERSE DRUG REACTION WRONG DRUG 1 1 1 1 1 1 2 2 2 3 3 4 4 5 5 12 17 17 0 2 4 6 8 10 12 14 16 18
Nemours is an internationally recognized children’s health system that owns and operates the Nemours/Alfred I. duPont Hospital for Children in Wilmington, DE, along with major pediatric specialty clinics in Delaware, Florida, Pennsylvania, and New Jersey. In October, 2012, it opened the full-service Nemours Children’s Hospital in Orlando, Florida. To learn more about Nemours, visit www.Nemours.org.
CONCLUSION
•Providing Nursing staff with clear and concise reports of medication errors that relate to their area of practice helps prevent errors from lessons learned.
•Frontline staff are area experts and can provide insight into failure mode effectiveness assessment (FMEA) for new processes. •CPOE eliminates legibility errors, but technology has its own group of potential exposures including keystroke errors and multiple charts open at one time.
•Educate staff to make copies of medication labels that come from community pharmacies with errors so that when errors occur, the Risk Managers at the outpatient pharmacy and their staff can be provided documents showing the cause of errors.
•Provide staff and parents with the right to stop any process when they feel a mistake may be occurring, and encourage them to speak out.
•Independent checks for high-alert medications by two staff members must be truly independent to be effective. As the majority of errors (54%) occur during administration, this is the last step to catch potential errors (5).
•Use the Ten Rights of Medication Safety.
•Continued research is needed in the outpatient pediatric setting so that we can continue to work towards error-free care.
REFERENCES
1. Rinke et al. Interventions to reduce pediatric medication errors. AAP Pediatrics, August 2014 P338 2. McPhillips HA, Stille CJ, Smith D et al. Potential medication dosing errors in outpatient pediatrics. Journal of Pediatrics 2005;147;761-7 3. American Nurse Today March 2010 P27 4. Kuehn BM. Group urges going metric to head off dosing mistakes. JAMA.COM Jamanetwork.com. Online published 21 May 2014. 5. Santell JP, Hicks R. Journal of Quality and Patient Safety. June 2005. Volume 31, Number 6, 348-353