Let me save you the heart ache of a medical error in a neonate or pediatric patient. Understanding how to prevent common pediatric medication errors is crucial in safeguarding our youngest patients.
This isn’t a discussion of how to determine appropriate dosing in infants and pediatric patients. We have many reliable and established resources like Neofax and Harriet Lane that provide evidenced based dosing recommendations in this population.
The greater concern is all the potential pitfalls that can occur in the process of getting that recommended dose to the patient from calculations and compounding to administration. The hazards of this execution are not talked about enough. Let’s change that.
Why Pediatrics are High Risk
Neonatal and pediatric patients are at a higher risk (31%) of medical error than the general population (13%)for several reasons including:
1. Lack of Medical Research
There are unique challenges to conducting research in non – adult patients. Children cannot provide consent. Parents or legal guardians make the decision for them. There must be consideration of a child’s emotional and physical maturation to handle to rigors of a clinical trial. Is it ethical?
2. Rapidly Changing Bodies
Unlike an adult, a child’s body systems are in an active state of maturation.
The stomach pH at 2 months old is very different than at 6 months.
Likewise, skin composition is very different at 12 months versus 24 months.
Water and fat composition also varies as children mature.
Also, liver and kidney function increases as the child develops.
All of these moving targets will affect how a child will respond to medication as they age.
3. Lack of Standard Dosing
Children undergo significant physical and metabolic changes as they mature. Because of this, dosing is usually calculated as a factor of body weight or body surface area. This necessitates calculation of doses. Whenever there are calculations there is a risk of error.
4. Medication Compounding
Non-standard or weight-based dosing means that medications will likely need to be made; another opportunity for error. Selecting the right starting ingredients, at the right concentrations and volumes and combining together with appropriate technique are all steps that can introduce medication errors in pediatric patients.
5. Communication Gap
Kids are less able to communicate and associate the way they feel to medical intervention. Caregivers may misrepresent or all together miss adverse events.
The need for specific investigation into drug development for non-adults has been gaining much attention. The Best Pharmaceuticals for Children Act incentivizes research that improves safety and efficacy of medications use by children. Since 2002 they have conducted 51 pediatric trials and updated 23 drug/device labels to reflect best use in the pediatric population.
While policies change at an administrative level, here are 4 areas to be mindful of in your practice to prevent medication errors in neonatal and pediatric patients.
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1. Reasonable Weight
Dosing weight errors in non-adult patients are very common. The most common cause for error is discrepancies between pounds (lbs) and kilograms (kg) and decimal errors.
All drug dosing recommendations from reputable sources will be reported in kilograms. However, the general Western population is more familiar with weight in lbs.
Pop Quiz 
A typical scenario is a patient being weighed on a scale that results as lbs or the caregiver reports the weight in lbs but it is transcribed into the chart as kg.
For example, a patient who weighs 7lbs is documented as weighing 7kg (a 2.2x increase in weight).
A decimal error can result from a weight being entered as 23kg instead of 2.3kg.
What can you do to prevent these weight-based medication errors?
Have a reasonable expectation of weight
Always consider the weight relative to age in pediatric patients. Have a general idea of weight for pediatric patients at landmark ages. If a patient varies significantly in weight than expected it is worth investigating and verifying prior to dosing. This could prevent significant medication errors in the pediatric population.
The Joint Commission recommendation for avoiding weight based errors in pediatric patients:
Kilograms should be the standard nomenclature for weight on prescriptions, medical records and staff communications.
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2. Emergency Response
The inherent risks in pediatric healthcare are amplified in emergency situations.
To be prepared familiarize yourself with the Braselow Tape.
The Braselow Tape is a color coded “tape” that is placed along the length of a child to determine their “color zone”.
Each zone is represents an estimate of their weight and length with corresponding pre-calculated doses and equipment sizes that would be most appropriate.
It eliminates the need for non-standard dose calculations during the most acute phases of pediatric emergencies which helps to prevent medication errors.
3. Independent Double Check
As the name implies, a double check should always be done with pediatric calculations. The independence needs to be emphasized.
It is NOT a double check of your calculations. They are performing their own calculations without the influence of your work.
Each person should perform calculations as if they received the initial order. Do not show them your work, do not share your thought process or final answer prior to their independent calculations.
If both of you do not arrive at the same value, I recommend having a 3rd practitioner independently perform the calculations to identify and prevent a potential medication error.
The unit on alligation calculations which are regularly used in neonatal and pediatric populations to compound specific fluid concentrations is a useful resource for those working with this population.
Use dosing calculators from reputable sources like LexiDrug Pediatrics or Micromedex Pediatrics to assist with calculations.
4. Per Day vs Per Dose
Some drug references will provide dosing recommendations per day or per dose or both. Penicillin is an example where the dose is provided as per day and per dose within the same drug reference based on indication.
Be mindful of this. Always double check the units of the recommended dose.
Pop Quiz
Providing medical care to neonatal and pediatric patients requires a high level of preparedness, diligence and intention. I hope this unit has provided you with some guidelines to help standardize your approach and avoid these potential pitfalls.
Share your near miss errors in the comments. Let’s learn from each other!
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The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.
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