1. How to Harm Children with Medicines – a guide for pharmacists*
James Wallace – Yorkhill Hospital Glasgow
Peter Mulholland – Southern General Hospital Glasgow
*With apologies to Professor Imti Choonara

2. Learning outcomes Definitions & identification of medication errors
Extent & nature of medication errors in children
Strategies to avoid errors

3. Definition
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer

4. In the UK
The UK Department of Health in 2000 recognised that a weakness of the NHS is in preventing serious incidents in which patients are harmed or experience poor outcomes of care. 

5. NPSA 2007. Safety in doses: improving the use of medicines in the NHS.
National Reporting and Learning System - 60,000 incidents reported in 18 months
Children ≤ 4years involved in 10% incidents where age stated

6. NPSA 2007. Safety in doses: improving the use if medicines in the NHS
Recurring themes
Problems with injectable medicines
Gentamicin – NPSA alert issued Feb 2010
Children being treated in non-paediatric areas
Errors in dose calculation
10 fold errors
Vaccines

14. Most common error type Dosing errors 28% Route of administration 18%
MAR transcription & documentation %
Wrong date %
Frequency %

15. Classification of errors
Wrong dose administered
Dose omitted
Additional dose given
Wrong drug given
Wrong infusion rate
Dispensing / labelling error
Wrong I/V concentration
Wrong patient
Wrong route
Other

16. How do errors occur?
Medication errors are almost never caused by the failure of a single element or the fault of a single practitioner
Usually the result of the combined effects of ‘latent’ errors in the system combined with ‘active failures by individuals

17. Why do individuals make errors ?
Psychological state
Interruptions
Lack of information
Calculation errors -Electronic calculators
Corporate livery
Confirmation bias
Tiredness/stress
Noise
Temperature
Workload/staffing levels / Rotas

19. Unreasonable to expect absolute perfection or error free performance from any person
Systems need to be in place to minimise the risk of medication errors by providing opportunities for checks, good communication, and a stress free environment
In any post error evaluation process - any system deficiencies should be identified and corrected before placing all responsibility on human error

21. Why are children at greater risk of medication errors
Why are children at greater risk of medication errors? & What can WE do about it?
Drug doses calculated individually
Based on age, weight, surface area
More calculations
Weights change rapidly (esp neonates)
10-fold errors
Inadequate information
Incorrect use of dose information resources

22. Why are children at greater risk of medication errors
Why are children at greater risk of medication errors? & What can WE do about it?
Lack of suitable dosage forms and concentrations
Need for complex calculations & dilutions by medics/nurses/pharmacy

23. Medication errors with the potential to cause harm are eight times more likely to occur in neonatal intensive care units (NICUs) compared with hospital patient care areas for adults.
Kaushal R, Bates DW, Landrigan C et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285:2114–20.

24. Medication errors in children more likely with unlicensed medicines
Percent of prescriptions
Percent of errors
Off-label
23%
10%
Unlicensed 7%
17%
13% of errors caused moderate harm and 60% of these involved unlicensed and off label drugs. Medication errors causing moderate harm were significantly more likely to be associated with unlicensed and off label drugs than licensed drugs
Reference: Arch Dis Child, published early online 4 December 2010

25. Children can’t always tell us
if we’re about to make a mistake
if they suffer adverse effects
Children have less internal reserves with which to ‘buffer’ the effects of errors

33. Strategy for error reduction
Reporting system
Review of errors
Identification of system weaknesses
Change of policies / procedures / training / availability of information
Feedback to staff
Non disciplinary
Confidential telephone line

34. What has been done? Ward-based clinical pharmacist 95%
Computerised physician order entry with decision support 68%
e.g. drug-allergy; drug-dose; drug-drug interaction checks
Computerised medication administration record %
Kaushal R et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:

35. Interventions Increased input from clinical pharmacists
Prospective review of medication orders in two children’s hospitals
Analysed 10 error prevention strategies
3 interventions had the greatest potential impact
clinical pharmacists might have prevented 81.3%
computerised prescribing might have prevented 72.7%
improved communication between staff might have prevented 47.7%
In combination 98.5% could potentially have been prevented.
Fortescue et al, Pediatrics. 2003;111:722-9

36. Simpson et al (Arch Dis Child 2004) Glasgow
Pharmacist led education programme
Errors fell from 24/1000 to 5/1000
Change in staff increased rate to 12/1000
Still lower than before intervention

37. Ways to avoid? Education for prescribers (& testing?)
Rules regarding zeroes/decimal points
Ready access to paediatric drug dosing texts
Avoid calculations by use of standard doses/dose charts etc
Provide drug monographs of high risk drugs
Individualised emergency drug dose chart

38. Other ways to avoid? Check weight is appropriate for age
Ensure dose is not > adult dose
Do not accept poor/ambiguous prescriptions
Accurate patient history taking
involve families
maintain patient profiles for regular patients

39. Other ways to avoid? Avoiding interruptions Double checking
tabards
quiet room
medication nurse/technician
Double checking
Root-cause analysis of all major errors

40. Purchasing for safety Handwritten drug name Verbal drug name
Assess all new products before introducing:
Handwritten drug name
Verbal drug name
Dose overlap
Presentation
Directions & frequency
Indication
Alphabetical location
Packaging & labelling
Information

41. Storage for safety Resolution
Numerous commercially available parenteral medications indicated for neonates were being stored on shelves in the central pharmacy adjacent to similar-sounding and similar-appearing medications for adults.
Resolution
Neonatal medications were segregated into a “neonates only” portion of clearly marked shelving. Purchasing personnel created this new segregated shelving space and allocated purchased medications to this space when deliveries arrived from the distributor

43. Summary Acknowledge the problem Quantify it’s extent and causes
Cease finger pointing
Analyse all errors via quality assurance
Evaluate proposed solutions

44. Summary of learning points
Establishment of a medication error review scheme is essential
A ‘no blame’ system of reporting should be established
Suitable paediatric reference sources should be readily available
Users should be aware of problems relating to unlicensed or off label drug use
Patients / carers should have suitable information

45. Any system that helps prevent medical mistakes, by helping doctors come forward without the fear of being blamed, would hold real benefits for the NHS Michael Wilks, chairman of the British Medical Association's Medico-Legal Committee