When Poor Math Skills, Inattention Can Do Real Harm
Toronto—While the problem of 10-fold medication errors is very real, the authors of
a recent study say part of the solution is also very clear: Pharmacists need to be more involved in patient care.
In the review of the decimal-point errors over 5 years at a university-affiliated pediatric hospital, the authors noted, "Pharmacists decrease pediatric medication error and, in our study, pharmacists were the most frequent intercepters and reporters of pediatric 10-fold medication errors."
Other possible solutions include more math education for hospital staff, identifying high-risk medication, and establishing fixed-dose weight-based order sets for those high-risk medications, according to the study published recently in the journal Pediatrics.
Researchers at the Hospital for Sick Children in Toronto looked at 252 10-fold medication errors out of 6,643 medication-related safety reports, for a mean reporting rate of 0.062 per 100 total patient days. Of those, the patient was harmed in 22 cases.
The errors involved morphine more than any other drug and opioids more than any other class. Numerous practices and mistakes contributed to the problem, according to the authors, who wrote, "Intravenous formulations, paper ordering, and drug-delivery pumps were frequent error enablers. Errors of dose calculation, documentation of decimal points, and confusion with zeroes were frequent contributing causes to 10-fold medication error."
The authors note that one often-touted solution for medication errors, computerized physician order entry (CPOE), did not help the situation that much. "Because of the overriding of recommendations, ignoring of alerts, and the inability of CPOE to recognize certain 10-fold under doses, we identified CPOE as an enabler of pediatric 10-fold medication error," they write. "Although CPOE decreases certain types of medication error in pediatric inpatients, it is by no means infallible."
They suggest that CPOE could be much improved if systems were designed "in a standardized fashion that incorporates pediatric-specific dosing."
While most of the problems involved administering too much medication, one area involved the downside of too-low dosages.
"The only class of drugs that we report as being associated with repeated 10-fold under dosing is antimicrobial agents," the authors point out. "This finding is very important when one considers the need to achieve rapid therapeutic efficacy in cases of febrile neutropenia, severe infection, or developing sepsis."