Errors at the prescribing level often translate directly to errors at the dispensing level, as pharmacists may misinterpret medication names, units, and inadvertently dispense the wrong concentration of a medication or even the wrong medication.
Because the weight of the child is usually not written on the prescription, it is difficult for pharmacists to double-check the physician's calculations. Past surveys indicate that only two-thirds of pharmacists corroborate physicians' calculations.3
Calculation errors in converting milligrams to milliliters from physician orders are common and may go undetected because neither the drug concentration nor the medication volume administered are documented routinely in a patient's chart.
To avoid administration errors, the AAP encourages nurses to check medication calculations with another qualified healthcare provider; confirm the identity of the patient before administration of each medication dose; and utilize medication ordering and dispensing systems when these are available. Nurses also should question an unusually large or small volume/dosage and verify that the order is correct in these situations.2
One of the best recommendations pediatricians can give to parents is to use a dosing syringe rather than a teaspoon in dosing children, because the volume of liquid delivered by teaspoons varies considerably. In a study of 100 pediatric encounters, the teaspoon used to measure medications by the parents was evaluated quantitatively. The range of "teaspoon" volumes was 1.5 mL to 5 mL with a mean volume of 2.95 mL and a median volume of 2.5 mL.4-6
Fixing the problem
There are both high-tech and low-tech solutions to reducing medication errors in pediatric patients. Low-tech solutions include providing patients in the office with medication sheets for commonly recommended OTC medications such as acetaminophen, ibuprofen, and diphenhydramine that list the name of the medication, concentration, and the appropriate dose and dosing interval based on the patient’s weight. It has been demonstrated that graphic sheets that not only indicate the appropriate dose of medication but also the schedule for administration significantly improve compliance.7 As mentioned earlier in this article, writing the weight of the child and the dosage on all prescriptions facilitates corroboration by the pharmacy.
There are many mobile apps and web tools I’ve discussed in previous articles to help with weight-based dosing. These include Pedi QuikCalc, Epocrates, and Medscape, with the latter 2 having web-based portals that can be used in conjunction with the electronic health record (EHR). In addition, I always recommend that parents utilize Dr. Barton Schmitt’s Pediatric SymptomMD application ($2.99) which integrates dosing information for ibuprofen and acetaminophen, in addition to Benadryl and other antihistamines. All these apps have video reviews on www.medgizmos.com.
James Broselow, MD, creator of the Broselow Pediatric Emergency Tape, has developed the SafeDosePro mobile application (http://w2.ebroselow.com/). This is a bargain at $99 dollars per year and expedites lookup capability for medications. Unique to the SafeDosePro mobile application is the ability to use a mobile device to scan the bar code on a medication label. Combined with the inputted weight of the child and the treatment indication, the app quickly provides a display of the medication dosage. The application also keeps a log of medication administration, useful in the office and inpatient setting, that can be transmitted to the EHR.
One final note
Pediatricians should be aware that the US Food and Drug Administration (FDA) in conjunction with the American Society of Health-System Pharmacists (ASHP) has begun an initiative to standardize drug concentrations. This is called the Standardize 4 Safety Initiative, and its 3-year goal is to develop and implement national standardized concentrations for intravenous and oral liquid medications.
1. Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics. 2014:134 (2):338-360.
2. Stucky ER; American Academy of Pediatrics Committee on Drugs; American Academy of Pediatrics Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics. 2003;112(2):431-436.
3. Mitchell AL. Challenges in pediatric pharmacotherapy: minimizing medication errors. Medscape website. Available at: www.medscape.com/viewarticle/421220. Published May 21, 2001. Accessed September 12, 2017.
4. Simon HK, Weinkle DA. Over-the-counter medications: do parents give what they intend to give? Arch Pediatr Adolesc Med. 1997;151(7):654-656.
5. McMahon SR, Rimsza ME, Bay RC. Parents can dose liquid medication accurately. Pediatrics. 1997;100(3 pt 1):330-333.
6. Hyam E, Brawer M, Herman J, Zvieli S. What's in a teaspoon? Underdosing with acetaminophen in family practice. Fam Pract. 1989;6(3):221-223.
7. Yin HS, Dreyer BP, van Schaick L, Foltin GL, Dinglas C, Mendelsohn AL. Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med. 2008;162(9):814-822.