Children are more vulnerable to hospital drug errors, agency says

Hospitalized children who receive medications made for adults are at greater risk for suffering harm, a national organization said today while issuing recommendations on how to avoid drug errors.

The Joint Commission, a private group that accredits US hospitals and other healthcare organizations, is sending out a Sentinel Event Alert urging hospitals to adopt standards for safely calculating the doses of medicine for children and encouraging manufacturers to formulate drugs specifically for children.

The standards include:

-- weighing all pediatric patients in kilograms and using that weight for all prescriptions, medical records, and staff communication;
-- not dispensing or administering high-risk drugs until the patient has been weighed, unless it is an emergency;
-- requiring prescribers to spell out how they calculated the dose per weight so a pharmacist, nurse, or both can double-check the result;
-- using formulations and medicines made specifically for children whenever possible;
-- clearly differentiating products that have been repackaged for children from adult formulations.

Children's Hospital Boston adopted those measures as standard practice several years ago, Laura Bobotas, director of clinical regulatory compliance, said in an interview.

Most medication mistakes that hurt pediatric patients result from incorrect dosage, the Joint Commission said. Determining how much of a medication to give is more complicated than dividing an adult dose by the size and weight of a child. Children metabolize drugs differently than adults and their growth can be affected in ways not anticipated in clinical trials of drugs for adults.

Only 30 to 35 percent of medications on the market are used in children or have specific dosage formulations for them, Al Patterson, director of pharmacy at Children's, said in an interview. That means hospital pharmacists have to prepare medications to meet specific needs.

Children's is about to roll out a bar-coding system that would allow a nurse to check if the medication about to be given is the right dose, the right formulation for administering it, and going to the right child.

A study in this month’s Pediatrics estimated that one of every 15 hospitalized children are hurt by medication errors. A fifth of those mistakes were called preventable.