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Client Safety, Risk Management & Innovation Within the Paediatric Population

Melanie G. Acosta

Humber College Practical Nursing

NURS 218

Paul Jeffrey

Friday October 13th, 2023

Client Safety, Risk Management & Innovation Within the Paediatric Population

Medication errors, a concerning issue within the healthcare industry are an issue for both adult

and paediatric populations. Medication errors or ‘M/E’s’ can be defined as any avoidable circumstance

that could result in improper pharmaceutical use or patient injury while the drug is under the healthcare

professional’s, patients, or consumer's control. (FDA, 2019). These errors cover a wide range of mistakes,

including wrong doses, administration errors, medication interactions or packaging mix ups. Such errors

can occur at any stage of the medication pathway, from orders, transcribing, dispensing and

administration (ISMP Canada, 2016). However, when it comes to children, the effects of med errors can

be even more severe. While both adults and children are prone to medication errors, the difference in

physiology and dosing for these two populations require different considerations. The appropriate usage

of medications meant for children is not sufficiently studied. Due to the intricacy of weight-based

dosage, children are 3x more likely than adults to make potentially harmful drug errors and inaccurate

dose ordering errors are prevalent (Feyissa et al., 2020). Many factors, such as professional ignorance,

inadequate training, illegible prescriptions, professional fatigue, inconsistent drug formulations, and

poor communication skills, contribute to the occurrence of medication errors in children. In this context,

it is important to explore the unique challenges associated with med errors in children, as well as the

measures used to reduce and prevent these errors in this particularly vulnerable demographic.

The Medication Pathway and Defining the Area of Focus

The Medication Pathway, an essential element of healthcare consists of several connected

procedures to guarantee the safe and efficient administration of drugs. An important element in the

pathway is the process of med orders. Medication orders are prescriptions that doctors, and other

medical professionals write specifying the type, dose, frequency, and route of administration for a

particular drug and patient (Tully, 2012). The area of focus within this pathway centers around the

accuracy and precision of these medication orders specifically with children. Drug errors can often be
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traced back to unclear or inaccurate drug orders. Factors such as illegible handwriting, use of

abbreviations, or even a failure to consider the patients specific needs can contribute to such errors. In

context of the paediatric population, 13% of prescriptions written for children contain errors compared

to prescriptions written for adults (Conn et al., 2019). Thus, a key objective of the medication pathway is

ensuring the quality of orders, emphasizing precise and standardized documentation to minimize the

potential of errors in pediatric care.

Analysis of Area of Focus

Pediatric medication order errors are a serious issue in healthcare that demands careful

investigation. According to a study published in the Journal of Pediatric Nursing, pediatric patients are 3x

more likely to experience medication errors compared to adults (Marufu et al., 2022). Various factors,

including changes in weight-based dosing, age-specific drug formulas, and the inherent difficulties of

communicating with children may be attributed for this increased risk. The pharmaceutical formulations

designed for children and adults differ significantly in today's healthcare setting, presenting an important

challenge for pediatric doctors. There are few, if any, pediatric-specific formulations among numerous

drugs, which are instead primarily intended for adult usage. As a result, doctors frequently practice "off-

label" prescribing in which drugs that are licensed for use in adults are given to children, frequently with

modified dosages. However, with the use of “off-label” prescribing these medications are not approved

by Health Canada for pediatric use (ISMP Canada, 2021). This practice raises great concern since children

have distinct physiological and developmental characteristic that can affect the drug response.

Additionally, pharmacists face a challenging job by compounding adult drugs to meet the needs of a

child, while being well intending this can add complexity as well as risk for error in the compounding

process (ISMP Canada, 2021). A medication order error that results in the improper dosage of the

prescription can have serious effects on a child’s health. An example is the overdosing of opioids, where

simple prescribing errors can lead to respiratory depression, seizures or even death.
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Delving deeper into the area of focus, its apparent that pediatric medication order errors extend

beyond the basic drug prescription. 25% of medication order errors were due to incorrect calculation of

dosages emphasizing on inappropriate prescription writing (D'Errico et al., 2022). Within the area of

pediatric medication orders, it’s important to focus on prescription writing, its components and if poorly

done the affects. The format and accuracy of prescriptions are extremely important when it comes to

pediatric medication orders since poor formatting can have a significant negative impact on the health

and safety of children. The absence of vital information such as a child’s age or weight can make it more

difficult to tailor the medication to the needs of the pediatric patient. To ensure the safety and efficacy of

treatment for our youngest patients, it is crucial that pediatric prescriptions are carefully written and

well-structured.

Recommendation

When writing a prescription for both adults and children, the patient’s current weight is

frequently needed to determine a safe and effective dose. Children come in a variety of ages and

weights, ranging from premature neonates weighing less than 1kg to adult sized adolescent (D'Errico et

al., 2022). The dose of a prescribed drug may differ significantly from what is recommended when

medication errors occur due to incorrect or unreported patient weights (Pennsylvania Patient Safety

Advisory, 2009). The implementation of pediatric-specific prescribing methods, which stresses the

prioritization of a child's weight (in Kg’s) and age in prescriptions, is an essential recommendation that

deserves greater attention. Each prescription should express the weight in kilograms (Kg) for medications

that require weight calculations as it’s known to be the standard unit used in healthcare. By customizing

prescriptions to child specific characteristics such as weight and age, healthcare providers can

significantly reduce the risk of medication order errors. This ensures that the correct amount of

medication is being administered as well as minimizes the risk of adverse effects of the adult drug. There

are many settings especially outpatient and ambulatory settings in where the physician overlook
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including such details. Without the patients weight it makes it complicated for pharmacists to verify if

the dosage being prescribed is appropriate for the child (Conn et al., 2019). At most times, the

pharmacists rely on the average weights of children based on age however that can be inaccurate as

children change in weight more regularly than adults (Conn et al., 2019). The weight and age of the

pediatric patient should be mentioned on each prescription wither it being written or electronically and

should be mandated federally in Canada.

The recommendation to implement pediatric specific prescribing is not only a patient centre

approach but a cost effective and straight forward solution. A change in the workflow and attitude of

healthcare professionals is primarily required to incorporate a child's weight and age into prescription

orders. The recommendation as well does not require increasing staff or investing in elaborate

technology. In fact, many hospitals in Canada already have electronic health record systems in place that

are easily able to accept such data inputs. Pharmacists can effectively prepare correct medication

dosages reducing the risk of compounding errors. Additionally, nurses may feel more comfortable

administering medications since they will have a clear, age-appropriate prescription lowering the risk for

error.

Conclusion

In summary, medication order errors within the paediatric population press a concern that

requires comprehensive attention and reform. Children are suspectable to these errors, which frequently

occur due to a lack of pediatric specific prescribing guidelines. The absence of including the weight and

age of a child on a prescription can lead to severe consequences for children (D'Errico et al., 2022).

Implementing pediatric specific prescriptions by always including the weight and age of the child can not

only promote patient safety, but a cost effective and straightforward solution in reducing the risk of

medication errors. This practice should be mandated federally in Canada as it benefits the patient,

physician, pharmacist, and nursing staff as well ensures our vulnerable population is protected.
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References

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Conn, R. L., Kearney, O., Tully, M. P., Shields, M. D., & Dornan, T. (2019). What causes prescribing errors
in children? scoping review. BMJ Open, 9(8). [Link]

D’Errico, S., Zanon, M., Radaelli, D., Padovano, M., Santurro, A., Scopetti, M., Frati, P., & Fineschi, V.
(2022). Medication errors in pediatrics: Proposals to improve the quality and safety of care
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Feyissa, D., Kebede, B., Zewudie, A., & Mamo, Y. (2020). medication error and its contributing factors
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