What causes prescribing errors in children? Scoping review

High-risk pediatric medications: A listing proposal by interdisciplinary consensus technique

INTRODUCTION

Pediatric patients are more likely to experience medication-related errors and serious associated harms. The identification of high-risk medications (HRM) and their study in special populations, such as children with excess body weight, is a part of safety improvement strategies.

OBJECTIVE

To generate, through a consensus technique structured by an interdisciplinary group of pediatricians and hospital pharmacists, an operational and updated list of HRM for hospital use in children over 2 years of age. The document was part of a collaboration project between the Spanish Society of Hospital Pharmacists and the Spanish Society of Pediatric Hospital Medicine.

METHODS

The study was carried out in two sequential phases: a) preparation of a preliminary list of HRM through bibliographic review and b) subsequent application of the double-round Delphi method to agree on a definitive list of HRM. The results obtained were validated by calculating the probability of chance agreement and the modified Kappa statistic for each drug.

RESULTS

The original list obtained by bibliographic review included 26 pharmacological classes and 96 drugs. Of the total of 37 experts, 32 (86.4%) completed both rounds of the Delphi. The final consensus list of HRM incorporated 24 pharmacological classes and 100 drugs. The modified Kappa statistic reflected a high percent agreement (94.9%) in the consensus reached by the participants.

CONCLUSION

This list can establish a tool for future studies and interventions to improve the safety of medications in general pediatric population, as well as in high-risk subgroups, such as pediatric patients with excess body weight.

Child Age and Risk of Medication Error: A Multisite Children's Hospital Study

OBJECTIVE

The objective of this study was to examine associations between patient age and medication errors among pediatric inpatients.

STUDY DESIGN

Secondary analysis of data sets generated from 2 tertiary pediatric hospitals: (1) prescribing errors identified from chart reviews for patients on 9 general wards at hospital A during April 22 to July 10, 2016, June 20 to September 20, 2017, and June 20 to September 30, 2020; prescribing errors from 5 wards at hospital B in the same periods and (2) medication administration errors assessed by direct prospective observation of 5137 administrations on 9 wards at hospital A. Multilevel models examined the association between patient age and medication errors. Age was modeled using restricted cubic splines to allow for nonlinearity.

RESULTS

Prescribing errors increased nonlinearly with patient age (P = .01), showing little association from ages 0 to 3 years and then increasing with age until around 10 years and remaining constant through the teenage years. Administration errors increased with patient age, with no association from 0 to around 8 years and then a steady rise with increasing age (P = .03). The association differed by route: linear for oral, no association for intravenous infusions, and U-shaped for intravenous injections.

CONCLUSIONS

Older age is an unrecognized risk factor for medication error on general wards in pediatric hospitals. Contributors to risk may be the clinical profiles of these older children or the general level of attention paid to medication practices for this group. Further investigation may allow the design of more targeted interventions to reduce errors.

Counting on Change: Conquering Challenges in Teaching Pharmaceutical Calculations

All pharmacists are expected to accurately perform pharmaceutical calculations to ensure patient safety. In recent years, there have been trends in declining performance on the North American Pharmacist Licensure Examination related to calculations. Understanding the cause of this decline and determining methods to correct underlying issues could benefit pharmacy administration, faculty, students, and patients. The aims of this commentary are to present the factors impacting the students' pharmaceutical calculations abilities, discuss the consequences of declining math skills, and provide a call to action for scholarship of teaching and learning pertaining to calculations, as well as increased administrative support to rectify this challenge.

Incidents et accidents médicamenteux en établissement de santé : une analyse descriptive au sein d’un CHU mère-enfant de 2018 à 2022

Background

The safety of care provided is based on an analysis of medication incidents and accidents.

Objective

The primary objective was to describe medication-related incidents and accidents (I&A) within a university-affiliated hospital.

Methods

This retrospective descriptive study was based on data from a 500-bed mother-child university-affiliated hospital. All I&As declared between April 1, 2018, and March 31, 2022, were considered. The analysis included all medication-related I&As that occurred during an admission or in an outpatient setting. Some variables were recoded manually. Descriptive statistical analyses were performed.

Results

A total of 23 284 I&As were considered, including 7578 medication-related I&As. Daily averages of 15.9 ± 14.0 I&As and 5.2 ± 0.3 medication-related I&As were reported. There were 22.4 medication-related I&As/1000 inpatient days. The majority of medication-related I&As occurred in surgery (20%, 1530/7578), oncology (19%, 1405/7578), and pediatrics (16%, 1200/7578). Most were associated with incorrect dosing (21%, 1575/7578); infiltration, extravasation, or removed lines (19%, 1405/7578); and omissions (16%, 1205/7578). Physical consequences were reported in 15% (1158/7578) of the medication-related I&As. Conversely, psychological consequences were reported in less than 1% (44/7578) of medication-related I&As.

Conclusions

This study provides a comprehensive descriptive profile over a 4-year period. Most of the reported I&As did not lead to consequences for patients. The sharing of ratios promotes comparative analysis with other facilities and can contribute to discussions about risk reduction. A culture of reporting events is present within this health care facility.

Reconstitution of oral antibiotic suspensions for paediatric use in households: a cross-sectional study among caregivers of 3-5-year-old children from a selected district, Sri Lanka

INTRODUCTION

Reconstitution of oral pediatric antibiotic suspension by primary caregivers plays an essential role in determining the overall health outcome of the child. Incorrect reconstitution techniques could lead to underdosing, overdosing, or introduction of infection. Underdosing could lead to non-resolving infection and antimicrobial resistance.

OBJECTIVES

To assess the practice and associated factors on reconstitution of oral pediatric antibiotic suspensions (OPAS) among primary caregivers of 3-5-year-old children in a selected district in Sri Lanka.

METHODS

A cross-sectional study was carried out among 835 primary caregivers selected using two-stage cluster sampling at field clinics to assess practices for the reconstitution of OPAS. A live demonstration of the reconstitution of the OPAS was assessed by a checklist. Associated factors with caregiver practices on reconstitution were assessed using Chi-square with the statistical significance level set at 0.05.

RESULTS

A total of 820 respondents were recruited and completed the study (response rate = 98.2%). Overall, 56.0% displayed good performance in the demonstration of reconstitution of oral pediatric antibiotic suspension. Poorest performances were observed in shaking the bottle to loosen the powder (Correct: 53.7%), topping up the bottle with water up to the marked line (Correct: 58.0%), and filling the water below the marked line in the bottle (Correct: 59.0%). Caregivers in urban areas compared to rural and estate regions (45.6% vs. 22.7% and 26.5% respectively) and caregivers aged 35 years or above compared to less than 35 years age group (31.5% vs. 22.5%) performed the reconstitution of OPAS poorly. Parental factors, namely age, gender, level of education, and geographical region (urban/rural/estate) were significantly associated with the performance in reconstituting the oral paediatric antibiotic suspension (p = 0.002, p < 0.001, p < 0.001, and p < 0.001 respectively). Factors related to the child, specifically whether they attend preschool and whether they have an older sibling, were found to have a significant association with the correct execution of the reconstitution of OPAS (p = 0.017, and p = 0.030 respectively).

CONCLUSIONS AND RECOMMENDATIONS

A significant number of primary caregivers displayed poor practice in key steps during the reconstitution of OPAS, which could have a negative impact on the health of the child. Targeted place-based behavioural change health programs with the use of infographic leaflets/ posters may correct the practices of caregivers.

Improved paediatric antimicrobial prescribing with a smartphone application: a before and after interventional study

INTRODUCTION

Children have a high consumption of antimicrobials that require complicated decision-making by prescribers. Despite this, antimicrobial stewardship (AMS) interventions are often not translated into paediatric medicine. Script is a smartphone application (app) launched in Auckland, New Zealand to support decision-making for antimicrobial prescribers. The aim was to improve adherence to existing local clinical guidelines for both adult and paediatric infections.

METHODS

Inpatient and emergency department antimicrobial prescriptions were prospectively collected and evaluated for guideline adherence. Baseline prescribing data were collected and compared with prescribing at 4 months and 1 year after the app was launched. Prescriptions were graded as 'appropriate' or 'inappropriate' by investigators. Grading was done blinded to timing of the prescription relative to the intervention.

RESULTS

Following the launch of the Script app, guideline adherence significantly increased from 241 of 348 (69%) antimicrobial prescriptions graded as appropriate during the baseline period to 301 of 359 (83%) after 4 months (p<0.0001). This improvement from baseline was sustained at 1 year with 263 of 323 (81%) adherence (p<0.001). At 1 year, this improvement could be demonstrated separately for medical, surgical and emergency department prescriptions.

CONCLUSION

There was a significant and sustained improvement in adherence to paediatric antimicrobial guidelines following the introduction of a prescribing support app. The need to seek guidance for antimicrobial doses due to the age-based and weight-based calculations in paediatrics may mean that AMS interventions such as decision support and prescribing tools are particularly well suited to paediatric prescribing.

STAMP: a 5-year project to reduce paediatric prescribing errors

We describe an ongoing quality improvement project to reduce paediatric prescribing errors following our earlier interventions previously published.

Potential Drug-Related Problems in Pediatric Patients-Describing the Use of a Clinical Decision Support System at Pharmacies in Sweden

The clinical support system Electronic Expert Support (EES) is available at all pharmacies in Sweden to examine electronic prescriptions when dispensing to prevent drug-related problems (DRPs). DRPs are common, and result in patient suffering and substantial costs for society. The aim of this research was to study the use of EES for the pediatric population (ages 0-12 years), by describing what types of alerts are generated for potential DRPs, how they are handled, and how the use of EES has changed over time. Data on the number and categories of EES analyses, alerts, and resolved alerts were provided by the Swedish eHealth Agency. The study shows that the use of EES has increased. The most common type of alert for a potential DRP among pediatric patients was regarding high doses in children (30.3% of all alerts generated). The most common type of alert for a potential DRP that was resolved among pediatrics was therapy duplication (4.6% of the alerts were resolved). The most common reason for closing an alert was dialogue with patient for verification of the treatment (66.3% of all closed alerts). Knowledge of which type of alerts are the most common may contribute to increased prescriber awareness of important potential DRPs.

Parental Factors Affecting Pediatric Medication Management in Underserved Communities

BACKGROUND

Medication errors and adverse drug events are common in the pediatric population. Limited English proficiency and low health literacy have been associated with decreased medication adherence, increased medication errors, and worse health outcomes. This study explores parental factors affecting medication management in underserved communities.

METHODS

Using qualitative methods, we identified factors believed to affect medication management among parents. We conducted focus group discussions between December 2019 and September 2020. We recruited parents and health care professionals from local community partners and a tertiary care children's hospital. Sessions were recorded and transcribed. Three investigators created the coding scheme. Two investigators independently coded each focus group and organized results into themes using thematic analysis.

RESULTS

Eleven focus groups were held (n = 45): 4 English-speaking parent groups (n = 18), 3 Spanish-speaking parent groups (n = 11), and 4 health care professional groups (n = 16). We identified 4 main factors that could impact medication delivery: 1) limited health literacy among parents and feeling inadequate at medication administration (knowledge/skill gap), 2) poor communication between caregivers (regarding medication delivery, dosage, frequency, and purpose) and between providers (regarding what has been prescribed), 3) lack of pediatric medication education resources, and 4) personal attitudes and beliefs that influence one's medication-related decisions.

CONCLUSIONS

The compounding effect of these factors - knowledge, communication, resource, and personal belief - may put families living in underserved communities at greater risk for medication errors and suboptimal health outcomes. These findings can be used to guide future interventions and may help optimize medication delivery for pediatric patients.

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors

Electronic medication management (eMM) systems are designed to improve safety, but there is little evidence of their effectiveness in paediatrics. This study assesses the short-term (first 70 days of eMM use) and long-term (one-year) effectiveness of an eMM system to reduce prescribing errors, and their potential and actual harm. We use a stepped-wedge cluster randomised controlled trial (SWCRCT) at a paediatric referral hospital, with eight clusters randomised for eMM implementation. We assess long-term effects from an additional random sample of medication orders one-year post-eMM. In the SWCRCT, errors that are potential adverse drug events (ADEs) are assessed for actual harm. The study comprises 35,260 medication orders for 4821 patients. Results show no significant change in overall prescribing error rates in the first 70 days of eMM use (incident rate ratio [IRR] 1.05 [95%CI 0.92-1.21], but a 62% increase (IRR 1.62 [95%CI 1.28-2.04]) in potential ADEs suggesting immediate risks to safety. One-year post-eMM, errors decline by 36% (IRR 0.64 [95%CI 0.56-0.72]) and high-risk medication errors decrease by 33% (IRR 0.67 [95%CI 0.51-0.88]) compared to pre-eMM. In all periods, dose error rates are more than double that of other error types. Few errors are associated with actual harm, but 71% [95%CI 50-86%] of patients with harm experienced a dose error. In the short-term, eMM implementation shows no improvement in error rates, and an increase in some errors. A year after eMM error rates significantly decline suggesting long-term benefits. eMM optimisation should focus on reducing dose errors due to their high frequency and capacity to cause harm.

[Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice]

Therapeutic drug monitoring to optimize psychopharmacotherapy in children and adolescents - Update and guidelines for practice Abstract. Despite the improved evidence base, many uncertainties remain in child and adolescent psychiatric pharmacotherapy about the efficacy and tolerability of drugs, which are often prescribed off-label or in combination therapy in this age group. Because medium- to long-term use is unavoidable in many cases, clinicians should minimize adverse drug reactions as far as possible and tailor an effective dosage to the individual characteristics of the patient. Not only are children and adolescents particularly vulnerable to certain adverse drug effects, they are also exposed to iatrogenic risks from dosing or application errors, which can lead to under- or overdosing with correspondingly negative effects on the success of the therapy. In addition to determining a strict indication, it is therefore essential to establish precise dosage and systematic monitoring of the safety of the psychopharmacotherapy. This article introduces therapeutic drug monitoring as a useful clinical tool and describes how its correct application in practice can improve the efficacy as well as the safety and tolerability of psychotropic therapy in children and adolescents for the immediate benefit of patients. Keywords: Psychopharmacotherapy, adverse drug reactions, pharmacovigilance, therapeutic drug monitoring, quality assurance.

Participatory Design of a Medication Module in an Electronic Medical Record for Paediatric Palliative Care: A Think-Aloud Approach with Nurses and Physicians

BACKGROUND

Electronic medical records (EMRs) play a key role in improving documentation and quality of care in paediatric palliative care (PPC). Inadequate EMR design can cause incorrect prescription and administration of medications. Due to the fact of complex diseases and the resulting high level of medical complexity, patients in PPC are vulnerable to medication errors. Consequently, involving users in the development process is important. Therefore, the aim of this study was to evaluate the acceptance of a medication module from the perspective of potential users in PPC and to involve them in the development process.

METHODS

A qualitative observational study was conducted with 10 nurses and four physicians using a concurrent think-aloud protocol and semi-structured qualitative interviews. A qualitative content analysis was applied based on a unified theory of acceptance and use of technology.

RESULTS

Requirements from the user's perspective could be identified as possible influences on acceptance and actual use. Requirements were grouped into the categories "performance expectancies" and "effort expectancies".

CONCLUSIONS

The results serve as a basis for further development. Attention should be given to the reduction of display fragmentation, as it decreases cognitive load. Further approaches to evaluation should be taken.

The effect of a decision support system on the incidence of prescription errors in a PICU

What is known and objective

Paediatric intensive care patients are at high risk for prescription errors due to the more complex process of medication prescribing. Clinical decision support systems (CDSS) have shown good results in effectively reducing prescription errors. A specific dosing CDSS was developed that can check and suggest normal dose, dose limits and administration frequencies. This study aimed to assess the effect of this CDSS on protocol deviation (as measure of prescription error) types and frequency in a paediatric intensive care unit (PICU).

Methods

A retrospective observational study was conducted evaluating 9342 prescriptions in a 4‐month period before and after the implementation of a CDSS in the PICU of the University Medical Center Utrecht. Medication forms were reviewed to identify protocol deviations (and therefore possible prescription errors). The incidence and nature of deviations from evidence‐based protocols that were unintended and needed to be adjusted, were determined.

Results and discussion

In the period before the dosing CDSS, we identified 45 protocol deviations in 5034 prescriptions (0.89%), 28 of which could not be justified (0.56%) and 11 needed to be adjusted (0.22%). In the period after the implementation of the CDSS, there were 21 protocol deviations in 4308 prescriptions (0.49%) of which ten without a valid reason (0.23%) of which two were adjusted (0.05%).

What is new and conclusion

The specific dosing CDSS was able to significantly reduce unintentional prescription dose deviations and the number of prescriptions that needed to be adjusted, in an existing low incidence situation.

Burden of Treatment among Elderly Patients with Cancer: A Scoping Review

Background: The objective of this scoping review is to understand how treatment burden is experienced in elderly patients with cancer and what the most prevalent dimensions of treatment burden are among this population. According to one conceptual model, there are six dimensions of treatment burden, including financial, medication, administrative, time/travel, lifestyle, and healthcare. Methods: A scoping review methodology framework was used to collected data from EMBASE CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline/PubMed, Scopus, Web of Science, Embase, and Cochrane from 2000 to March 2020. Studies which focused on treatment burden among elderly patients with cancer (+65 years) were selected. Data were extracted using a standardized proforma. Results: The results identified 3319 total papers. Of these, 24 met the inclusion criteria and were included in the scoping review. A significant proportion of these studies was conducted in the United States (n = 10) using self-reported, cross-sectional data. Financial burden was the most prevalent dimension of treatment burden, with 11 studies focusing on the direct and indirect costs associated with cancer treatment. Other but less obvious aspects of treatment burden elderly patients experienced included the length of time taken to access and administer treatment and medication-related burdens. Conclusions: Emerging findings suggest that the financial aspects of cancer treatment are a significant burden for most elderly cancer patients. Personalized healthcare interventions targeting ways to reduce and screen for treatment burden, particularly those related to cost, are urgently needed.

Comparison of Accuracy and Speed in Computer-Assisted Versus Conventional Methods for Pediatric Drug Dose Calculation: A Scenario-Based Randomized Controlled Trial

Pediatric emergency care is prone to medication errors in many aspects including prescriptions, administrations, and monitoring. This study was designed to assess the effects of computer-assisted calculation on reducing error rates and time to prescription of specific emergency drugs. We conducted a randomized crossover experimental study involving emergency medicine residents and paramedics in the Department of Emergency Medicine at Ramathibodi Hospital. Participants calculated and prescribed medications using both the conventional method and a computer-assisted method. Medication names, dosages, routes of administration, and time to prescription were collected and analyzed using logistic and quantile regression analysis. Of 562 prescriptions, we found significant differences between computer-assisted calculation and the conventional method in the calculation accuracy of overall medications, pediatric advanced life support (PALS) drugs, and sedative drugs (91.17% vs 67.26%, 86.54% vs 46.15%, and 89.29% vs 57.86%, respectively, P < .001). Moreover, there were significant differences in calculation time for overall medications, PALS drugs and sedative drugs (25 vs 47 seconds, P < .001), and computer-assisted calculation significantly decreased the gap in medication errors between doctors and paramedics (P < .001). We conclude that computer-assisted prescription calculation provides benefits over the conventional method in accuracy of all medication dosages and in time required for calculation, while enhancing the drug prescription ability of paramedics.

Drug-Related Problems in Prescribing for Pediatric Outpatients in Vietnam

BACKGROUND

Our study was conducted to determine the prevalence of drug-related problems (DRPs) in outpatient prescriptions, the impact of DRPs on treatment efficacy, safety, and cost, and the determinants of DRPs in prescribing for pediatric outpatients in Vietnam.

METHODS

A retrospective cross-sectional study was conducted on pediatric outpatients at a pediatric hospital in Can Tho, Vietnam. DRPs were classified according to the Pharmaceutical Care Network Europe classification (PCNE) of 2020. The study determined prevalence of DRPs and their impacts on efficacy, safety, and cost. Multivariate regression was used to identify the determinants of DRPs.

RESULTS

The study included 4339 patients (mean age 4.3, 55.8% male), with a total of 3994 DRPs, averaging 0.92 DRP/prescription. The proportion of prescriptions with at least one DRP was 65.7%. DRPs included inappropriate drug selection (35.6%), wrong time of dosing relative to meals (35.6%), inappropriate dosage form (9.3%), inappropriate indication (7.1%), and drug-drug interactions (0.3%). The consensus of experts was average when evaluating each aspect of efficiency reduction, safety reduction, and treatment cost increase, with Fleiss' coefficients of 0.558, 0.511, and 0.541, respectively (p < 0.001). Regarding prescriptions, 50.1% were assessed as reducing safety. The figures for increased costs and decreased treatment effectiveness were 29.0% and 23.9%, respectively. Patients who were ≤2 years old were more likely to have DRPs than patients aged 2 to 6 years old (OR = 0.696; 95% CI = 0.599-0.809) and patients aged over 6 years old (OR = 0.801; 95% CI = 0.672-0.955). Patients who had respiratory system disease were more likely to have DRPs than patients suffering from other diseases (OR = 0.715; 95% CI = 0.607-0.843). Patients with comorbidities were less likely to have DRPs than patients with no comorbidities (OR = 1.421; 95% CI = 1.219-1.655). Patients prescribed ≥5 drugs were more likely to have DRPs than patients who took fewer drugs (OR = 3.677; 95% CI = 2.907-4.650).

CONCLUSION

The proportion of prescriptions in at least one DRP was quite high. Further studies should evaluate clinical significance and appropriate interventions, such as providing drug information and consulting doctors about DRPs.

Establishing dose bands for commonly prescribed oral medications for children in the UK: Results of a Delphi study

OBJECTIVE

To establish weight-based dose bands for commonly used oral medicines, given in liquid forms, for children in the UK that could be used for prescribing and administering accurate and safe drug doses.

METHODS

A list of commonly prescribed, oral liquid medications was established from the medication dispensing database of four UK hospitals and a primary care database. The evidence base of currently used dose regimens for each drug was identified from paediatric reference books, summary of product characteristics and the literature. Then, weight-based dose bands were developed and a modified Delphi process was used to achieve healthcare professional consensus about the suggested dose bands for each drug.

RESULTS

Forty-six experts in paediatric medicines participated in the Delphi process (mean years of experience 17.3 ± 9.4 [standard deviation]) and assessed 45 oral liquid drugs in total. Four categories of weight-based dose bands were established: drugs with two dose bands (17.8%, 8/45), drugs with three dose bands (64.4%, 29/45), drugs with four dose bands (15.6%, 7/45) and drugs with five dose bands (2.2%, 1/45). The 46 participants reached consensus on all the suggested dose bands for 53.3% (24/45) of the drugs. Consensus was reached in the first round of the Delphi process for 91.7% (22/24) of the drugs and after two rounds for two drugs. No agreement was achieved on any of the suggested dose bands for 26.7% (12/45) of the drugs.

CONCLUSION

This study provides healthcare professionals with a set of recommended weight-based dose bands for commonly prescribed oral liquid drugs for children. These bands could establish the basis for change in clinical practice to reduce dosing errors and improve healthcare for children.

[Reduction of reconciliation errors in chronic pediatric patients through an educational strategy]

BACKGROUND

Medication reconciliation errors, also known as unintentional discrepancies, are frequent during admission, especially in chronic patients, and have an impact on safety. Educational interventions can be a reduction strategy.

MATERIAL AND METHODS

Quasi-experimental study, before-after design. Participants were chronic patients admitted into hospitalization services. Medication reconciliation was conducted at admission. The intervention consisted of a training to each prescribing physician with study contents and printed educational material. To study the association between intervention and change of frequency of unintentional discrepancies was made a logistic regression model, adjusting for selected variables.

RESULTS

A sample of 54 patients was studied in each stage. In the first stage it was observed that 42.6% of patients had at least one unintentional discrepancy. After intervention the proportion of patients with at least one unintentional discrepancy decreased to 24.1% (p = 0.041). In both stages, omission was the main category of unintentional discrepancy. The significant reduction after the intervention is maintained by controlling for variables such as emergency admission and pre-admission service.

CONCLUSIONS

Incidence of unintentional discrepancies in admission is high in chronic hospitalized patients and can be reduced through an educative strategy.