Children Are Three Times More at Risk than Adults
OAKBROOK TERRACE, Ill., April 11 /PRNewswire-USNewswire/ -- Medications
specifically made for adults and administered to children in health care
facilities are putting young patients at greater risk for drug errors,
according to a Joint Commission alert issued today to improve pediatric
safety.
The Joint Commission's latest Sentinel Event Alert addresses pediatric
medication errors, and urges greater attention to precautions such as
medication standardization, improved medication identification and
communication techniques, as well as the use of kilograms as the standard
weight measurement to calculate proper dosages.
Most of the harmful pediatric medication errors tracked during the past two
years by U.S. Pharmacopeia involved either an improper dose or quantity,
according to the Alert. Problems typically arise when hospitals and clinics
are forced to prepare special volumes or concentrations because the drugs are
formulated and packaged primarily for adults. The need to alter the original
medication dosage requires a series of calculations and tasks that increase
the chance for error.
"Children often lack the communication skills to tell caregivers if something
is wrong, which increases the responsibility of caregivers to carefully
monitor their care to keep them safe," says Mark R. Chassin, M.D., M.P.P.,
M.P.H., president, The Joint Commission. "Organizations and caregivers must
commit themselves to using effective risk reduction strategies to make a
difference in preventing pediatric medication errors."
To reduce the risk of pediatric medication errors, The Joint Commission's
Sentinel Event Alert suggests that health care organizations take a series of
specific actions, including:
-- Use the Joint Commission's National Patient Safety Goals and Medication
Management Standards to guide safe medication practices for pediatric
patients;
-- Weigh all pediatric patients in kilograms, which then becomes the
standardized weight used for prescriptions, medical records and staff
communication;
-- Do not dispense or administer drugs classified as high risk until the
patient has been weighed, unless it is an emergency situation;
-- Require prescribers to write out how they arrived at the proper dosage, as
dose per weight, so that the calculation can be double checked by a
pharmacist, nurse or both; and
-- Use pediatric-specific medication formulations and concentrations when
possible.
The Alert also encourages organizations to be open and transparent if an error
occurs in order to facilitate learning so that future errors can be prevented;
drug manufacturers to develop pediatric-specific formulations and to
standardize labeling and packaging of all medications; and parents to seek out
information and ask questions about their child's medications and to repeat
back instructions to health care professionals in order to avoid mix-ups.
The warning about pediatric medication errors is part of a series of Alerts
issued by The Joint Commission. Information and guidance provided in these
Alerts is drawn from The Joint Commission's Sentinel Event Database, a
comprehensive voluntary reporting systems for serious adverse events in health
care. The database includes detailed information about adverse events and
their underlying causes. Previous Alerts have addressed wrong-site surgery,
medication mix-ups, health care-associated infections, and patient suicides.
The complete list and text of past issues of Sentinel Event Alert can be found
on The Joint Commission website.
For more patient safety solutions, visit the Joint Commission International
Center for Patient Safety's free, online database of practices and
interventions to prevent adverse events at http://www.jcipatientsafety.org/.
Founded in 1951, The Joint Commission seeks to continuously improve the safety
and quality of care provided to the public through the provision of health
care accreditation and related services that support performance improvement
in health care organizations. The Joint Commission evaluates and accredits
more than 15,000 health care organizations and programs in the United States,
including more than 8,000 hospitals and home care organizations, and more than
6,300 other health care organizations that provide long term care, assisted
living, behavioral health care, laboratory and ambulatory care services. The
Joint Commission also accredits health plans, integrated delivery networks,
and other managed care entities. In addition, The Joint Commission provides
certification of disease-specific care programs, primary stroke centers, and
health care staffing services. An independent, not-for-profit organization,
The Joint Commission is the nation's oldest and largest standards-setting and
accrediting body in health care. Learn more about The Joint Commission at
http://www.jointcommission.org.
SOURCE The Joint Commission
Ken Powers, Media Relations Manager of The Joint Commission, +1-630-792-5175,
kpowers@jointcommission.org
