Sentinel Event Alert Paper: Preventing Pediatric Medication Errors Introduction The Joint Commission Sentinel Event Alert, Issue 39, 2008, pertains to pediatric medication errors and the risk mitigation strategies. This paper summarizes the content of the sentinel alert and its relation to the actual practical experience in the care of patients…
Hence reducing medication errors in the pediatric segment of the population is the challenge posed to healthcare service providers, particularly when medication errors among pediatric patients are preventable (The Joint Commission, 2008). Evaluation of why children are more prone to medication errors shows that there are several reasons. Several of the medications used in the treatment of children have been actually formulated and packed for adult use, and hence dilutions in concentrations are essential to make them suitable for use on children. For instance, conversion of adult based dosage medications to child dosages requires good mathematical calculation skills. The health care settings are based on adult care needs, and therefore deficient in training and skills required in the care of children. Organic functions like renal functions, hepatic functions, and immune functions are still in the development stage for children, which make them less physiologically tolerant to higher dosages of medications through medication errors. Finally, there is the aspect of communication, where young children are unable to communicate effectively regarding any affects the experience from adverse effects caused by the medications given to them (The Joint Commission, 2008). The risk mitigation strategies for medication errors to children involve strategies that are specific to pediatric patients. The Joint commission recommends three such strategies in a broad sense. The first strategy is to standardize and identify medications efficiently, which also includes the processes involved in drug administration. The second strategy is the involvement of pharmacy staff and other appropriate staff in overseeing medication management to children. The final strategy involves the judicious use of new and evolving technology on pediatric patients (The Joint Commission, 2008). There are additional recommendations of the Joint Commission to reduce the risk of exposure of children to medication errors. Weight is the basis for most dosage calculations and hence pediatric patients have to be weighed at the time of admission or at the earliest. Kilogram is to be used the unit of weight, and no high risk drug to be given till the weight has been taken. Inpatient and outpatient pediatric medication prescriptions have to carry the calculated dose and the manner in which the dosing has been determined. To the maximum extent possible medications given to pediatric patients have to be restricted to pediatric-specific formulations and concentrations. There should be clear differentiation between such pediatric-specific formulations and adult formulations repackaged for pediatric use. Comprehensive and continuous training programs in pediatric medications for the appropriate healthcare staff. Verbal and written communication on medications for children is to be provided to the children and the care givers, which will include any possible side effects. Pharmacist with adequate expertise on pediatric medications is to be available all the time. Medication procedures are to be put in place that also consists of pediatric medication prescribing and administration procedures (The Joint Commission, 2008). Clinical Practice Observations Smart infusion pumps are ...
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