Emergency Medical Services for Children and the American Academy of Pediatrics teamed up with the American College of Emergency Physicians, the Emergency Nurses Association, and many other stakeholder groups to discuss pediatric medication safety in the ED, resulting in numerous strategies for improvement and a set of recommendations.
“It is widely recognized that emergency physicians have a great opportunity and responsibility to improve the quality and safety of the care we provide, particularly for pediatric patients, who are a vulnerable population who demand advocacy,” says Lee Benjamin, MD, FACEP, FAAP. “Recognizing the need for improvement, as well as the need for a voice, Emergency Medical Services for Children (EMSC) and the American Academy of Pediatrics (AAP) took the first steps to advocate for pediatric medication safety in the ED, which can be an unfamiliar, hectic, challenging location for patients and families to receive care.”
Calling out the need to improve medication dispensing and administration within and after the ED places the patient and family at the center of the discussion, adds Dr. Benjamin. With engagement from the American College of Emergency Physicians, the Emergency Nurses Association, and numerous other stakeholder groups, EMSC and AAP initiated a panel discussion on pediatric medication safety in the ED, the outcomes of which were jointly published in Annals of Emergency Medicine and Pediatrics.
The panel decided on four key areas in need of being addressed to help decrease pediatric medication prescribing errors in the ED:
- Computerized physician order entry (CPOE): Pediatric medication is commonly dosed according to weight in kilograms. Computer-driven dosing calculations within CPOE take human error out of the calculation if patient weight is entered in the appropriate unit. However, if weight is entered incorrectly, if no upper or lower limits are placed into the electronic system, or if providers override recommendations, errors are more likely to occur. Errors may also occur due to CPOE systems being created by third-party businesses with variance in dosing recommendations between systems, explains Dr. Benjamin. Additionally, CPOE systems are commonly linked to clinical decision support within electronic medical records (EMR) that can assist in how best to manage many pediatric conditions and notify providers of medication allergies. Overall, it is believed that as EMR and CPOE use increases, the prevention of numerous medication errors can be expected.
- Standardized Formulary: No universally accepted, pediatric-specific standard dosing or limits currently exist. “The use of too many formulations of a medication is a large problem,” says Dr. Benjamin, “with numerous concentrations and delivery methods of individual medications available at any one hospital. If the wrong concentration or delivery mechanism is selected, the provider may order too low or too high a dose.”
- ED Pharmacists: Dr. Benjamin notes the around-the-clock availability of pharmacists to EDs, even if not physically present, minimizes errors. Studies also suggest that ED pharmacist implementation can be cost-effective and even cost-saving.
- Training in Pediatric Medication Safety: “If all emergency providers had the same standardized education specific to pediatric medication safety, variability in the approach to ordering, dispensing, and administering medications would be minimized, optimizing medication delivery in the ED,” says Dr. Benjamin.
The panel provides 18 recommendations that provide tangible, achievable opportunities to improve medication administration in the ED (Table). Prominent recommendations focused on administration errors include weighing patients in kilograms only without electronic conversion to pounds in the EMR, developing a standardized formulary with the smallest number of available concentrations of any single medication, utilizing clinical decision support to identify opportunities for improvement at the time of ordering medication, making pharmacists available at all times, and improving outpatient prescribing and education of those caring for children once home to correctly measure and administer medications.
“The first issue to address is awareness,” explains Dr. Benjamin. “It is crucial that emergency providers recognize that despite CPOE and EMRs, dangerous errors still occur. Ongoing attention, education, and competency evaluation are needed to ensure the safety of pediatric patients and maintain the high-quality standards for which all ED providers strive.”