Safety first: How to avoid missteps when prescribing medications

One of the challenges of being a pediatrician is ensuring that our young patients are medicated correctly. The process of weight-based dosing is fraught with potential mistakes because it involves several step calculations-the weight of the child, the dosage of the medication, the concentration of the medication, and the dosing interval. Medication errors are all too common in pediatric practice, no matter where medication is administered to children- hospital, home, or office. This article will describe many of the hazards of pediatric prescribing and detail the many ways pediatricians can avoid medication missteps.

“Death by decimal point”

According to a recent article, as many as 27% of all pediatric medication orders result in a medication error.¹ Medication errors fall into 3 categories-prescribing errors, dispensing errors, and administration errors-and each of these categories are associated with interventions that can reduce, but not eliminate, medication errors.

Prescribing errors

Poor handwriting as well as misunderstood abbreviations, calculation errors, and misplaced decimal points are all examples of “prescribing errors.” Whereas over-the-counter (OTC) acetaminophen is universally available in a concentration of 160 mg/5 mL, OTC ibuprofen is available in concentrations of 50 mg/1.25 mL as well 100 mg/5 mL. So it is easy for parents to administer the wrong dose of ibuprofen if practitioners communicate only the volume of the ibuprofen without specifying the concentration.

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The distribution of dosing charts for ibuprofen and acetaminophen help clarify our recommendations to parents (bit.ly/ibuprofen-dosage-table and bit.ly/acetaminophen-dosage-table).

Many of our prescription medications come in varying concentrations. For example, prescription prednisolone liquid comes in concentrations of 5 mg/5 mL, 10 mg/5 mL, 15 mg/5 mL, 20 mg/5 mL, and 25 mg/5 mL, and rushed pediatricians can easily prescribe the incorrect dose of prednisolone if they think in milliliters rather than milligrams. We must remember to avoid the use of terminal zeros in our prescriptions and always include a number to the left of the decimal point (Table).

Additionally, because medication abbreviations are confusing (MS may mean morphine sulfate or magnesium sulfate, for example, the American Academy of Pediatrics (AAP) recommends that pediatricians avoid abbreviations altogether and write out medication names and instructions clearly. Physicians also should use generic names to avoid brand confusion names, and spell out units (eg, use milligrams rather than mg).²

Also contributing to medication errors are varying dosages based on the indication (different dosages for respiratory infections vs meningitis for many antibiotics, for example) and a general unawareness of the maximum adult dose on the part of pediatricians. The AAP, therefore, recommends that pediatricians indicate the patient weight and milligram/kilogram dose on medication orders and prescriptions to enable pharmacists to more easily check the accuracy of prescribed medication doses.²

NEXT: Dispensing and administration errors

Dispensing errors

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

Administration errors

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.

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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.

Send your recommendations for safe medication prescribing to andrew.schuman@medgizmos.com

References

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.

Dr Schuman, section editor for Peds v2.0, is clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and editorial advisory board member of Contemporary Pediatrics. He is CEO of Medgizmos.com, a medical technology review site for primary care physicians.