Pediatric dose-rounding recommendations will make e-prescribing safer

Pediatricians trying to meet the government mandate to implement electronic prescribing have also struggled with another issue: How to safely round dosages up or down.

Now, an easy-to-adopt solution can remedy that problem.

A new report includes a primary set of recommended rounding tolerances for 102 of the drugs most commonly prescribed for your patients. The set, according to the report, can be used with current e-prescribing systems and should make the process much safer.

“The rounding algorithm that we developed in [this] project could be implemented by anyone. It does not require sophisticated programming,” S. Andrew Spooner, MD, MS, one of the project investigators, told Contemporary Pediatrics eConsult. “But even in 2011, the very concept of allowing the computer to compute any sort of dose, rounded or not, is still relatively new.”

Rounding has long been a concern because precise individualized weight-based dosing for pediatric medications is elusive.

“Although pediatric electronic prescribing systems are increasingly being used in pediatric care, many of these systems lack the clinical decision-support infrastructure needed to calculate a safe and effective rounded medication dose. This infrastructure is required to facilitate tailoring of established dosing guidance while maintaining the medication's therapeutic intent,” Spooner and his colleagues wrote in the study.

The researchers interviewed 19 pediatric health care and pharmacy experts to create initial rounding tolerances and then coupled that with a Delphi process for a consensus on the rounding tolerances.

The researchers said their literature review resulted in 3 categories for medication rounding: Medications for which rounding is used judiciously to retain the intended effect, medications that are rounded with attention to potential unintended effects, and medications that are rarely rounded because of the potential for toxicity.

In a small subset of medications, inadequate data existed to provide rounding recommendations.

In 2008, at the beginning of the study, lead investigator Kevin Johnson, MD, wrote in a publication of the AAP’s Council on Clinical Information that the goal of the project, Safety Through E-Prescribing System Tools (STEPSTools), was “ to build a small suite of tools that can be used nationally to provide a compounded formulation knowledge base and to provide information about dose rounding. These tools will be constructed in a way that facilitates the access to the knowledge for browsing/education (as might be needed by community pharmacies) as well as for integration into e-prescribing systems (as will be required by e-prescribing vendors).”

Johnson pointed out then, “Although many (but not all) e-prescribing systems have tools in place to help with dosing and to alert about potentially unsafe prescribing, virtually no systems have adequately dealt with compounded forms of medications (try ordering levothyroxine) or have addressed an even more common issue: Should the calculated dose of Digoxin 3.2 milliliters be rounded up to 4, down to 3, or given as calculated?”

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