Pediatric Medication Safety

Next week, July 28 from 12-1PM Eastern, Pharmacy OneSource (my day job) will be hosting a webinar on Pediatric Medication Safety. It is free! I encourage you all to sign up: https://www2.gotomeeting.com/register/788883355

The presenter will be Elora Hilmas, PharmD, BCPS. She is currently the PGY1 Residency Coordinator at the Alfred I. duPont Hospital for Children in Wilmington, Delaware. She graduated from University of Maryland School of Pharmacy and completed her PGY1 and Pediatric PGY2 residencies at The Johns Hopkins Hospital in Baltimore, Maryland. Elora has presented three times at the Annual Maryland Patient Safety Conference and has taught a lecture in the Medication Safety Elective offered at the University of Maryland School of Pharmacy. She is a co-inventor of Pharmacy OneSource’s Accupedia product and has won a Healthcare Hero award in the category of Advancements in Health Care from the Baltimore Daily Record for her work on standardizing concentrations.

I wrote a recent newsletter for work and re-print portions of it here:

It does not take much in the way of web searching to identify what a problem pediatric medication safety presents to health care. In an April 2008 Sentinel Event Alert published by The Joint Commission, Stu Levine from the ISMP is quoted saying that inpatient pediatric adverse drug events are three times more likely than adults in the same population. The report goes on to state that, in another study, a rate of adverse drug events in pediatrics was on the order of 11%. The Joint Commission publication goes on to list risk reduction strategies to prevent these tragic events. Our most vulnerable patients need our most rigorous attention and care.

A report last week out of Johns Hopkins underscores that the problem of pediatric medication safety is still very much with us. In their analysis of 821 pediatric medication errors, they found that half of these were in patients less than 1 year of age, 90% of these in patients less than 6 months. "The most common causes of dosing errors attributed to misinterpretation of the patient's weight, mathematical errors of computation, misinterpretation of orders, giving extra doses or missing doses." They go on to indicate that technology can improve safety by including double- and triple-checks into the systems.

Pediatric medication safety is still a very big problem. The margin for error is just too small.

~charles