Joint Commission Alert Targets Pediatric Medication Errors

The Joint Commission issued a Sentinel Event Alert on Friday about errors with medications specifically made for adults but administered to children in health care facilities, saying the errors are putting young patients at greater risk. The alert asks facilities to pay more attention to precautions such as medication standardization, improved medication identification, communication, and the use of kilograms as the standard measurement to calculate proper dosages.

Most of the harmful pediatric medication errors tracked during the past two years by U.S. Pharmacopeia involved an improper dose or quantity, according to the alert, which says USP's MEDMARX database shows nearly 2.5 percent of pediatric medication errors in 2006-2007 led to patient harm.

"Children often lack the communication skills to tell caregivers if something is wrong, which increases the responsibility of caregivers to carefully monitor their care to keep them safe. Organizations and caregivers must commit themselves to using effective risk reduction strategies to make a difference in preventing pediatric medication errors," said Dr. Mark R. Chassin, M.P.P., M.P.H., president of the Joint Commission, an Oakbrook Terrace, Ill.-based organization that works to improve the safety and quality of health care.

The alert suggests specific actions that include using the Joint Commission's National Patient Safety Goals and Medication Management Standards; not dispensing or administering drugs classified as high risk until the patient has been weighed, unless it is an emergency situation; requiring prescribers to write out how they arrived at the proper dosage, as dose per weight, so a pharmacist can double-check the calculation; and using pediatric-specific medication formulations and concentrations when possible. The alert is available at www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm.

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