PedsConLive Staff

A 1-month-old boy (weight, 5 kg) was prescribed clonidine (5 mg [1 mg/kg/dose] PO q8h) for neonatal abstinence syndrome. His parents filled this prescription at a local pharmacy. After taking a few doses of the medication, the boy became extremely lethargic. He was seen at the clinic and was found to be hypotensive and was admitted to a nearby hospital.

What is the problem here?



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After several 5 mg doses of clonidine, this 5 kg boy became extremely lethargic and hypotensive. What went wrong?

Top 10 Common Medication Errors-Drug #9: Clonidine

A gastrostomy tube–dependent 5-year-old girl who weighed 20 kg presented with a 2-day history of fever and lethargy. Urine and blood samples were obtained for culture at that time. The patient was sent home without medication because the clinician thought that the patient might have a viral respiratory infection.

Two days later, the urine culture turned positive for 

sensitive to only ciprofloxacin. The clinician thus called in a prescription to a local pharmacy for ciprofloxacin suspension (200 mg via G-tube bid [10 mg/kg/dose]). After the patient received 2 doses of the medication, the parents noticed that the G-tube was clogged off.

What’s the problem here?

Please click here for the answer and discussion.

A prescription was called into the local pharmacy for ciprofloxacin suspension (200 mg via G-tube bid [10 mg/kg/dose]). After the patient received 2 doses of the medication, the parents noticed that the G-tube was clogged off. What’s the problem here?

Top 10 Common Medication Errors -- Drug #7 -- Ciprofloxacin

A 5-year-old boy (20 kg) with sickle cell disease presented with a 2-day history of increasingly severe back pain. A detailed workup showed no signs of infection. The patient’s parents did not want their son to take narcotics for the pain. Thus, the boy was given a prescription for ketorolac -- 10 mg PO every 6 hours x 5 days [0.5 mg/kg dose]).

Ketorolac is a good option for relieving pain in patients with sickle cell disease, but there can be a problem with how this agent is prescribed for children.

Common Medication Errors: Drug #6: Ketorolac

 In this series, I focus on 10 errors commonly seen in the pediatric outpatient setting.

A 22-day-old neonate (gestational age, 37 weeks; weight, 4 kg) with otitis media was seen by his pediatrician. On presentation, he was febrile and looked jaundice. His bilirubin level was slightly above the upper limit of normal.

The clinician prescribed 200 mg of ceftriaxone (50 mg/kg) IM x 1 for the otitis media. The 1-g ceftriaxone vial was mixed with 2.1 mL of 1% lidocaine to a final concentration of 350 mg/mL. The dose was drawn up and administered accordingly.


 Ceftriaxone is a third-generation intravenous cephalosporin that is often used in the pediatric population for an array of infections ranging from pneumonia to otitis media. This antibiotic has the advantage of once-daily dosing, and it can be given intravenously or intramuscularly. This is especially beneficial in the outpatient setting: a single dose of ceftriaxone administered intramuscularly can be given to a pediatric patient who presents with a first episode of uncomplicated otitis media. 
  

The problem, however, is that ceftriaxone should be generally avoided in neonates, especially those whose bilirubin level is elevated because ceftriaxone can displace bilirubin from its binding site.

 The free bilirubin can cross the blood-brain barrier and cause kernicterus, which can be deadly. 
  

Another example of medication that should be avoided in neonates is oral ibuprofen. Medications that contain a high amount of sodium benzoate should also be avoided because benzoate can displace bilirubin from its binding site. High levels of benzoic acid (≥ 99 mg/kg/d) may also lead to gasping syndrome in neonates.

Another problem in this case is that sterile water for injection (SWI) rather than 1% lidocaine should be used to reconstitute the ceftriaxone vial in patients younger than 3 months. Potential mistakes can occur in which too much lidocaine is erroneously given to young patients, leading to toxicity.
 
 References
 1. Kaushal R, Goldmann D, Keohane C, et al. Adverse drug events in pediatric outpatients. 

Top 10 common medication errors-and how to avoid them: Drug #1: acetaminophen.

 Top 10 common medication errors-and how to avoid them: Drug #2: insulin.

 Oct 18, 2012. 
 4. Taketomo CK, Hodding JH, Kraus DM. 

18th ed. Hudson, Ohio: Lexi-Comp; 2011.
 
  

Ceftriaxone is used to treat an array of infections and can be given once daily IV or IM. However, it should generally be avoided in neonates, especially those with high bilirubin levels. This case demonstrates how problems can -- and do -- occur with this agent.

Top 10 Common Medication Errors-Drug #3: Ceftriaxone

Medication errors in the pediatric population occur in both the inpatient and outpatient settings. According to one study, pediatric medication errors occur at an approximate rate of 16% in the outpatient setting.

It is impossible to list all the potential medication errors that can occur. In this series, I will focus on 10 errors that are commonly seen in outpatient clinics. In a 

, I focused on a common error associated with infant acetaminophen.

Diabetes mellitus was newly diagnosed in an 11-year-old boy (110 kg). His endocrinologist prescribed insulin glargine, 5U subcutaneously at bedtime, along with insulin aspart on a sliding scale with meals and at bedtime.

The physician's office does not yet have computer physician order entry (CPOE), so the insulin glargine order was written on a prescription pad. The patient’s mother brought the prescription to the local pharmacy, and the pharmacist filled the prescription with 50 units of insulin glargine to be administered at bedtime.

The pharmacist has filled this prescription incorrectly with 50 units of insulin glargine instead of 5 units- probably because an unapproved abbreviation (ie, U) was used in writing the prescription.  The “U” may have been mistaken for a zero. This medication error can be prevented by writing out “units.”

lists commonly used unapproved medical abbreviations that clinicians should try to avoid.

  If CPOE is used in the clinic setting, this can also help prevent errors due to illegible prescriptions.

It is also helpful for the clinician to show the parents and/or the patient how to draw up the dose so that they will also be able to catch the dispensing mistake if it occurs. Even though insulin mistakes do not occur often, they can be detrimental when they do.

Table – Dangerous or Unapproved Abbreviations or Dose Designations

Kaushal R, Goldmann D, Keohane C, et al. Adverse drug events in pediatric outpatients. 

So J. Top 10 common medication errors-and how to avoid them: Drug #1: acetaminophen. Sept 19, 2011. http://www.pediatricsconsultantlive.com/display/article/1803329/2103387



 Eight dangerous/unapproved abbreviations or dose designations considered unacceptable for use. Retrieved from website: med.stanford.edu/shs/update/archives/FEB2004/chart.pdf



 King WJ, Paice N, Rangrej J, et al. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients.

Beware handwritten prescriptions for insulin and use of abbreviations....this case illustrates the dangers.

Top 10 Common Medication Errors-Drug #2: Insulin

It is impossible to list all the potential medication errors that can occur. In this series, I will focus on 10 errors that are commonly seen in outpatient clinics. The medications include acetaminophen, clonidine, ketorolac, vaccines, carbamazepine, amoxicillin/clavulanic acid, ciprofloxacin, insulin, ceftriaxone, and hydralazine and hydroxyzine.

Acetaminophen, 90 mg PO q6h prn, was prescribed for a 6-kg febrile infant with otitis media. The mother obtained children’s acetaminophen (160 mg/5 mL) from the local pharmacy. After she opened the product, however, she did not know how to administer the medication to her child. She was confused and called the clinic.


Infant acetaminophen, 80 mg/0.8 mL, was taken off the market early this year, and most local pharmacies now only carry the 160 mg/5 mL concentration. The problem is that the product labeling does not give any instruction to consumers on how to administer an infant dose. Moreover, most products come with a dosing cup rather than an oral syringe or dropper. Parents may perform some calculations and figure out how much (in mL) to pull out from the bottle to give to their child; however, mathematical errors often occur. The result may be under-dosing, or worse-over-dosing.
Even the dropper that used to come with infant acetaminophen often led to mistakes because the recommended dosages for an infant often required the administration of more than 1 dropperful of medication.

To prevent errors in acetaminophen dosing, you can provide the parent with an oral syringe or dropper and demonstrate how much to draw up from the 160 mg/5 mL concentration bottle. A pictogram can also help decrease parent dosing errors.

 These measures may be trivial, but they can definitely prevent errors.
 

References
1. Kaushal R, Goldmann D, Keohane C, et al. Adverse drug events in pediatric outpatients. 

 2007;7:383-389.
2. Yin HS, Mendelsohn AL, Fierman A, et al. Use of a pictographic diagram to decrease parent dosing errors with infant acetaminophen: a health literacy perspective. 

Infants acetaminophen, 80 mg/0.8 mL, was taken off the market early in 2012, and most pharmacies now only carry the 160 mg/5mL concentration. The label, however, does not provide instruction on how to administer an infant dose. Here, another major problem plus simple measures to prevent under- or over-dosing.