Improving medication safety in the ED: 18 recommendations reflect joint effort
Lee S.Benjamin, M.D., FACEP, FAAP and Karen S.Frush, M.D.
“My child died from a medication error.”
These words from a parent whose child died at a highly respected hospital silenced
the multidisciplinary panel discussing pediatric medication safety in the emergency
department (ED). The conference, convened by the AAP Committee on Pediatric Emergency
Medicine and Emergency Medical Services for Children, resulted in recommendations
from the Academy, the American College of Emergency Physicians and the Emergency Nurses
Association. The recommendations are outlined in the policy Pediatric Medication Safety in the Emergency Department, which is available at https://doi.org/10.1542/peds.2017-4066 and will be published in the March issue of Pediatrics.
Evidence shows that pediatric patients in any environment experience higher rates
of medication errors than adults, and the risk of error can be amplified by the high-risk
setting of the ED. As a large majority of pediatric patients cared for in emergent
situations are seen in general EDs in the community setting, recommendations for safe
medication delivery must apply across the spectrum of acute care settings.
Meeting the challenges
Although complex, opportunities to improve medication safety consistently involve
system improvement and primarily fall into three realms: prescribing errors, ED administration
errors and home administration errors.
Within the ED, computerized physician order entry (CPOE) has significantly alleviated
prescribing errors, specifically those related to dose calculation. However, there
is room for improvement.
Having scales that weigh children in kilograms only, with the resulting input of weight
in kilograms only, will remove the common error of calculating medication dosage based
on pounds. Additionally, clinical decision support built into many electronic order
programs is proven to reduce prescriber error; however, alerts are commonly overridden,
introducing variability in dosing.
Another challenge is the lack of universally accepted pediatric standards regarding
dosing and limits, currently dictated by CPOE vendors who utilize various formularies.
By developing a standard pediatric formulary with specific concentrations and standard
dosing, providers can benefit from seamless education and practice patterns for prescribing
high-risk and frequently used pediatric medications. Having ED pharmacists review
these types of pediatric medications has had a positive effect in hospitalized pediatric
patients and likely will translate to the emergency setting.
When administering medications in the acute care setting, nurses have an opportunity
to verify dosing and ensure appropriate administration. In this arena, a limited number
of standardized concentrations for any one medication can improve safe medication
delivery, as will having premixed vials, automated dispensing cabinets and barcoded
medication processes. Utilizing a two-provider check for high-alert medications and
working in a distraction-free zone also will encourage safe medication administration.
The task of medication administration in the home can be daunting due to language
barriers, limited health literacy and use of non-standardized delivery devices. Providing
delivery devices alongside pictograms to aid in medication measurement decreases error
rates, as does the AAP-supported concept of milliliter-only dosing for liquid medication.
The policy describes 18 recommendations to improve medication safety in the ED. Providers
should evaluate the most high-impact, achievable recommendations to improve safe medication
delivery in their environment. Recommendations include the following:
Use a standard formulary for pediatric high-risk and commonly used medications, with
a reduced number of standardized concentrations.
Measure and record weight in kilograms only, and use length-based dosing tools when
a scale is unavailable or use is not feasible.
Implement and support the availability of pharmacists in the ED.
Promote use of distraction-free safety zones for medication preparation.
Create and integrate a dedicated pediatric medication safety curriculum into health
care provider training programs.
Dispense standardized delivery devices for home administration of liquid medications,
and use pictogram-based dosing instruction sheets.
Prescribe milliliter-only dosing for liquid medications used in the home.
As new processes and systems develop for medication prescribing and administration,
new challenges will arise. Stakeholders should ensure that all EDs are treating pediatric
patients with up-to-date processes to improve safe prescribing and administration.
Dr. Benjamin is a lead author of the joint policy and a member of the Pediatric Emergency Medicine
Committee of the American College of Emergency Physicians. Dr. Frush, also alead author, is a Chapter Affiliate member and former member of the AAP Committee
on Pediatric Emergency Medicine. She directed the AAP-Emergency Medical Services for
Children consensus conference on which the policy is based.