Joint Commission Alerts Of Pediatric Medication Errors

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Medications specifically made for adults and administered to children in health care facilities are putting young patients at greater risk for drug errors, according to a Joint Commission alert issued today to improve pediatric safety.

The Joint Commission's latest Sentinel Event Alert addresses pediatric medication errors, and urges greater attention to precautions such as medication standardization, improved medication identification and communication techniques, as well as the use of kilograms as the standard weight measurement to calculate proper dosages.

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Most of the harmful pediatric medication errors tracked during the past two years by U.S. Pharmacopeia involved either an improper dose or quantity, according to the Alert. Problems typically arise when hospitals and clinics are forced to prepare special volumes or concentrations because the drugs are formulated and packaged primarily for adults. The need to alter the original medication dosage requires a series of calculations and tasks that increase the chance for error.

"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," says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint Commission. "Organizations and caregivers must commit themselves to using effective risk reduction strategies to make a difference in preventing pediatric medication errors."

To reduce the risk of pediatric medication errors, The Joint Commission's Sentinel Event Alert suggests that health care organizations take a series of specific actions, including:

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