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Johns Hopkins: Dosing errors common for pediatric heart patients 07.10.2009 A report out of Johns Hopkins underscores that the problem of pediatric medication safety is still very much with us. In their analysis of 821 pediatric medication errors, they found that half of these were in patients less than 1 year of age, 90% of these in patients less than 6 months. "The most common causes of dosing errors attributed to misinterpretation of the patient's weight, mathematical errors of computation, misinterpretation of orders, giving extra doses or missing doses." They go on to indicate that technology can improve safety by including double- and triple-checks into the systems.

Drug Dosing Challenges: Using Technology and Education to Improve Organization Performance 03.01.2009 The Joint Commission offers strategies for reducing dosing calculation errors including the use of computerized dosing calculators: "This technology can significantly reduce dosing errors by automating the dose calculation process for intravenous (IV) injectables and oral suspensions, as well as IV infusions. One specific type of calculator that has been helpful in improving dose calculation accuracy is the pharmaceutical algorithm computerized calculator or pac2."

World's Best Care Unit at Local Hospital (Click Headline for Video) 11.13.2008 OSF Saint Francis' Children's Hospital of Illinois, the first hospital in the nation to use InformMed's pac2 system, is getting world wide recognition. The hospital's Neonatal Intensive Care Unit has been named the top performing N.I.C.U in the world. The unit shared information on its teams multidisciplinary approach with more than 600 other N.I.C.U's around the world. A non–profit network, compared the data from those units concentrating on each units practices, outcomes, and patient care. The Children's Hospital was also in the top ten percent for the shortest length of stay in a hospital.

Joint Commission Alert: Prevent Pediatric Medication Errors Children Are Three Times More at Risk than Adults 04.11.2008 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. 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: Use the Joint Commission's National Patient Safety Goals and Medication Management Standards to guide safe medication practices for pediatric patients; Weigh all pediatric patients in kilograms, which then becomes the standardized weight used for prescriptions, medical records and staff communication; Do not dispense or administer drugs classified as high risk until the patient has been weighed, unless it is an emergency situation; Require prescribers to write out how they arrived at the proper dosage, as dose per weight, so that the calculation can be double checked by a pharmacist, nurse or both; and Use pediatric-specific medication formulations and concentrations when possible.

Medicine mix-ups harm hospitalized kids 04.01.2008 Medicine mix-ups, accidental overdoses and bad drug reactions harm roughly one out of 15 hospitalized children, according to the first scientific test of a new detection method. That number is far higher than earlier estimates and bolsters concerns already heightened by well publicized cases like the accidental drug overdose of actor Dennis Quaid's newborn twins last November. Researchers found a rate of 11 drug-related harmful events for every 100 hospitalized children. That compares with an earlier estimate of two per 100 hospitalized children, based on traditional detection methods. The rate reflects the fact that some children experienced more than one drug treatment mistake. The new estimate translates to 7.3 percent of hospitalized children, or about 540,000 kids each year, a calculation based on government data.

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