Pharmacy News

Joint Commission Spotlights Pediatric Adverse Drug Events

Kate Traynor

BETHESDA, MD, 11 Apr 2008—The newest Sentinel Event Alert from the Joint Commission calls on hospitals to reduce medication errors in pediatric patients.

The alert, which was issued today, follows a recent article in Pediatrics reporting that adverse drug events occurred in 11% of admissions to 12 children's hospitals, with most of the events resulting in "mild, temporary harm."

By calling attention to pediatric adverse drug events through the Sentinel Event Alert, the Joint Commission signaled that it will focus on the issue during accreditation surveys.

Jeff Low, clinical pharmacist specialist in pediatrics at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, said the Joint Commission's recommendations complement guidelines (PDF) issued in 2002 by the Pediatric Pharmacy Advisory Group (PPAG). Low is chair-elect of PPAG's board of directors.

Many of the risk-reduction strategies described in the Joint Commission's alert focus on weight-based dosing to reduce the risk of overdosage-related adverse drug events in pediatric patients.

For example, the Joint Commission recommends determining the weight, in kilograms, of all pediatric patients on admission to the hospital and within four hours after an emergency admission. Kilograms should be the standard unit of weight measurement in the hospital and on patient records and prescriptions, according to the alert.

The alert also advises hospitals to record weight-based dosage calculations on medication orders and prescriptions.

"One of the easy ways that we've found in order to do that is to use preprinted forms for pediatric patients which include a space for weight, which acts as a forcing function," Low said.

He said that after the forms were introduced at his hospital, the recording of pediatric patient weights on order sets increased substantially, from 56% to 98%. He said weight-based dosage calculations are recorded on the forms 91% of the time, up from 37% before the staff began using the forms.

Except in emergencies, so-called high-alert medications should never be administered to pediatric patients before determining their weight, according to the Joint Commission.

To reduce the risk of hospital personnel inadvertently injecting liquid oral medications into pediatric patients, the alert recommends that these medicines be prepared in oral syringes. Low called this a "relatively easy" change for hospital pharmacies to make.

Another Joint Commission recommendation is to purchase pediatric-specific formulations when they are available. When adult formulations are used, they should be clearly marked and dispensed into patient-specific unit dose containers.

Concentrated formulations of adult medications should be kept out of pediatric units, and pediatric and adult formulations of the same medication should never be stored in the same drawer of an automated dispensing unit, the alert states.

The Joint Commission requires "full pharmacy oversight" of the preparation, dispensing, and administration of pediatric and neonatal medications, according to the alert. To this end, the accrediting agency recommends that hospitals create pediatric satellite pharmacies or ensure that certain services, such as pediatric and neonatal critical care and oncology units, are assigned pharmacists and pharmacy technicians with "pediatric expertise."

A pharmacist with such expertise should be on call at all times, according to the Joint Commission.

The alert also recommends the "judicious" use of technology to reduce medication errors, including the development of bar-code systems that can handle pediatric dosages.

Low cited this as a challenge for hospitals because they will most likely need to work closely with vendors to ensure the accuracy of such systems.


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