Factors Contributing to Medication Errors in Pediatric Emergency Departments

Discuss about the Pediatric Medication Safety in Emergency Department.

In the recent years, medication error has been resorted to be one of the most common types of error occurring in different hospitals. The rate of medication error in the pediatric patients has also been increased and this is threefold to the rate of medication error in the adult patients. Researchers have recognize the pediatric emergency setting to be one of the place with the healthcare centers that have the high risk environment for the medication errors (Moreira et al. 2015). A number of factors may be considered the contributors for the development of such high-risk climate within the pediatric emergency department. Some of these factors are the handling of the complex patients with multiple medications that are seen to be mainly unknown to the emergency department staffs. Others are the lack of standard pediatric drug dosing as well as formulations. This also include weight based dosing, a hectic and strenuous environment with frequent interruptions from the different stakeholders as well as verbal orders (Sethuraman e al., 2015).  Many other contributors are the lack of clinical pharmacist in the Ed care tem that also accompanies the inpatient boarding status. Some of the other features include the improper use of the information technology systems that are mainly seen to lack the features of the pediatric safety and different transitions in the care. Many of the studies also refer to the fact that a large number of pediatric patients requiring emergency treatment are seen to go to the community care centers rather than the pediatric hospitals which might not have the expertise or the resources to treat emergency pediatric patients (Tanner et al. 2017). This assignment will try to shed more light on the topic and will highlight how different interventions can be adopted by professionals to help in developing a safe environment in the emergency department of the pediatric patients.

It has been seen that medication error is one of the most common form of error that occur in the emergency departments affecting children largely. Children become more vulnerable and get exposed to chances of preventable deaths than in comparison to that of the adults. One of the most important factors that is seen to contribute in medication error is that the children come in different sizes. This, in association with the necessity of weight based dosing is mainly seen to give a very hard time for the nursing professionals in the tensed climate in the emergency department that makes them conduct math errors (Patton  et al. 2017). One of the studies has given an example stating that 10-fold error is one of the most dangerous errors that threaten the life of individuals. The study has stated that children can be administered with 10-fold dose in a single syringe. However, this might never provide a visual cue to the professional who is administering the medication in comparison to giving the 10 prefilled syringes with medication like that when administering epinephrine to the adult patient (Ruddy et al. 2015). Therefore, this kind of situations results in the medication error in the emergency department exposing the child to unsafe practices. Another example that can be also stated is the use of heparin that researchers have stated to be risky for the administration to that of the small children.

Preventing Medication Errors in Pediatric Emergency Departments

It is extremely important for the professionals to perform math properly for conversion of the doses in the milligrams to that of the millimeters. This becomes one of the factors for occurrence of medication errors in the children who are admitted. Many of the researchers have opined  that in many cases math errors may be mainly because of the poor mathematics skills.. Moreover, other additional factors that may also result in math errors during dosing is the wok climate that often includes chaotic as well as hurried pace in the emergency department (Hansel et al. 2015). This is mainly because often the situations become such that dose calculations become nearly impossible. The professionals also face many other challenges when they try to administer medications in the emergency departments. It has also been seen that the medications that are administered and provided to the children in the emergency setting are used off-label. By this statement, it means that the medications are not been approved through the same type of trials in the pediatric patients as that happens for approval of medications for that of the adults in the Food and Drug administration approval (Stevens et al. 2015). It might also imply that sometimes, the medication may be available in the form that might not be considered proper and appropriate for the dosing of that of the small children. Many of the pharmacists are of the idea that even if the medications are available, the appropriate forms of medication might not be stocked by the respective facilities with mainly an aim to limit the inventory. Often nursing professionals are seen to uptake certain creative forms of doing solutions. Many a cases have been reported where nurses have been seen to use an intravenous form of medication that they mix with the cherry syrup and then administer them orally (Mc.Donald et al. 2018). When asked to the nurses, many of them were seen to be stated that they have seen their seniors to do so while many other say that as they work, they tend to follow the protocol. These kind of uncertain practices become one of the most plausible reasons for the occurrence. One another example that has been also noted in the observational studies was the administration of the small pieces of the dissolvable tablet for the sublingual administration in infants and toddlers (Bogner 2018).

During the time of the pediatric resuscitations, professionals of many healthcare emergency departments are seen to face different types of difficulties for the effective administration of the correct doses to that of the pediatric patient. This might be because if two reasons. It might be because they do not have a proper child resuscitation cart or it might also be because their carts may be prepared and arranged in ways by which it might mirror the adult carts. Nurses might also face apprehensions because a child is involved but they also express many stressors that result in occurrence of such medication errors in the pediatric patients (Neuss et al. 2016). Some of the stressors may involve lack of proper equipments for handling the situation, issue in sizing the equipments if the child. The nursing professionals are also seen to have a lack of the familiarity with the pediatric doses. They might also face various kinds of issues in calculation of the doses in the resuscitation situations. They may also face difficulty in quickly estimating the weight of the child, which might make the sessions of the calculations much more complicated. Many of the professionals prefer using the cart set up for reflecting the color zones of the Broselow Resuscitation Tape because of the size variance among different children. Many of the researchers are of the idea that the professionals should always weigh the children and record them by following the unit of kilograms rather than pounds (Goldman et al. 2018). There have been many evidences that have reported errors occurring among the professionals during the converting of the weight from pounds to that of kilograms and vice versa. Therefore, many of the healthcare authorities have kept the emergency departments where the scale is locked so that they can only weight in kilograms.

The Role of Computerized Physician Order Entry

Therefore, most of the researchers are of the opinion that there is an urgent need for alternation of the culture and these changes should be in regards with the patient safety. One of the most important aspect that needs to be changed is the reporting systems that would be non-punitive in nature and should be a blame free environment. This should be such that it would be possible for the higher authorities and professionals to know and uncover the different potential for the risks in the emergency departments (Guise et al. 2017). This knowledge would be also helpful in the development of the communication among team members that would include handoffs as well. However, one thing must be kept in mind by the healthcare organization is that the interventions which should be taken should be such that they would keep the patients in the centre of all the initiatives. This is indeed trying that changes in the culture of the work, organization and the emergency department would not only be lengthy but also difficult. This is mainly because it challenges the status quo but still professionals need to move forward for the improvement of the safety of the patients.

One of the effective ways for the decreasing if medication error in the emergency department is the computerized procedure for the physician order entry. Most of the researchers have observed that most of the medication errors actually take place during the ordering phase of the procedure of medications. Some of the different types of risks that remain associated with the pediatric form of weight based dosing is not utilizing the appropriate and correct weight as well as performing medication calculations not based on kilograms but on pounds (Cohen et al. 2016). Making improper calculations as well as causing the 10 fold errors is some of the other causes. In addition, the childhood obesity also invites the opportunity for doing error as frequent under dosing often takes place due to lack of knowledge of science  for guiding medication dosing in obese children. There the professionals also report for less scopes for prescription monitoring as well as double checking in the ED settings and even some of the calculations are done in absence of pharmacists. Therefore, in such arenas, implementation of the computerized physician order entry called the CPOE as well as the clinical decision support called the CDS with the features of electronic prescribing  have been seen to help in the reduction of the many of the errors. This is mainly because many of the CPOEs are obviated the need for simple dose calculations. However, the CPOEs cannot fully eliminate the chances of medication errors as the independently or the commercially developed CPOEs might fail or might not be helpful in addressing the critical unique pediatric dosing requirement (Sieberts et al. 2017). Kilogram only scales should be recommended for getting the weights of the patients, yet conversion to the system unit of pounds by the electronic heath record or by the operator might introduce opportunity for errors in the systems. Moreover, professionals might override CDs although it had proved its success I the reduction of the errors. However, the evidences has shown that with the growth of the use of the CPOEs, it can be expected that millions of medication errors will get decrease. It is also found that the emergency departments, which do not use CPOE, a procedure for the using of the preprinted forms of medication order also, have been shown to significantly take part in the reduction of the medication errors in the different types of settings. Thereby, help to be serving as the low-cost substitute for CPOE (Rinke et al. 2014).

The Importance of Increasing Knowledge Support

Increasing of the knowledge support is also seen to be one of the most effective methods for the prevention of any form of medication errors many of the researchers have observed that many of the medications are mainly prepared as well as dispensed by the electronic department without being verified by the pharmacists. Many of the rural healthcare centers are also seen to lack such pharmacists support. Some of the hospitals have reported that pharmacist provide a duty of 8 hours on weekdays but provide less than half of the hours on the weekends which make the department more vulnerable to such issues of medication errors (Lovergrove et al. 2015). Many of the hospitals as well as the different ER facilities also face barrier of financial constraints when they try to hire more number of pharmacists. In order to face the situation when in reality, pharmacists are not always present in the emergency departments; the Dr. James Broselow proposes the Broselow Tape in 1988. This is actually a color-coded tape that mainly helps in measuring and relating the height of the child to his or her weight. This is manly done in order to provide medical instruction to the professionals along with the medication dosages. The tape mainly helps by guiding the professionals or the clinicians in delivering the appropriate dosing. This method is still used widely in different of the facilities today (Beadoiun et al. 2015). The different issues that the Broselow Tape had helped in addressing about three decades ago are still addressed even today although billions of investments had been made in the technological advancements for finding out newer techniques to prevent the medication errors. However, it is advised that the emergency departments should continue in their quest of seeking different procedures for the accessing of the medication knowledge in the absence of the experiences pharmacists (Dayal et al. 2016).

One of another way to reduce the occurrences of medication safety is utilization of the standardized concentrations as well as developing better access to the different reference materials. Many of the researchers have correctly identified one of the major reasons of pediatric medication dosing errors. They have stated that lack of experiences of the healthcare professionals working in the emergency department in the administration of the various medications to the small children. Therefore, it is extremely important for standardizing the concentrations available for the given drug and having readily available medication references materials. This should be in working in combination of the pharmacists and the ED care providers working as the teams (Rees et al. 2017). Many of the CPOE solutions are seen in providing such reference materials. However, it is extremely important for the healthcare professionals in the setting to wade through volumes of information so that they can get to know about the pertinent answers for the pertinent answers to the specific questions that they face. A learning environment and knowledge base support should be developed in ways by which the physicians and the nursing professionals would be requiring quick access to the different types of appropriate dat they need for ensuring medication safety for the pediatric patients.

Expansion of the utilization of technology can also help in the reduction of the chances of medication errors for the pediatric patients in the emergency settins. Electronic health records have been seen to be a valuable option to the safe care of the patients. Researchers have been seen to term it as one of the best ways to prevent medication errors as they promise to be powerful and all knowing computer systems which would help in solving problems  with dosing and as well as administration the use of the computerized physician order entry (CPOE) and clinical decision support (CDS) with electronic prescribing. These have helped but they could not completely stop the occurrence of the medication errors because of their failures in the addressing of the unique pediatric dosing issues (Schumacher et al. 2018). This may include the weight conversion requirements from pounds to that of the kilograms. The emergency department should have leaders who need to be looking beyond the relying of the EHR technology solutions. Therefore, they are of the opinions that it is really the time for considering complementary solutions. These solutions would help in providing an enormous value in assuring proper medication administration for children. 

Enhanced training procedures are the other effective ways which can help in the changing of the culture that enhance increased knowledge and skills of the professionals providing service to pediatric patients. Researchers of the opinion that the lack of familiarity as well as experiences with the pediatric emergencies should be countered with more effective training for the clinicians who are seen to face the situations.  The leaders in the domains have thereby seen to recommend that the standard curriculum on the pediatric medication safety should be given the cope to be developed for all the healthcare professionals who have to deal with children in the pediatric emergency wards (Lion et al. 2015). These trainings should be such that it would include discussions of the common medication errors in the children. This training should also involve discussions of the improved tools that the professionals can use in the minimization as well as the elimination of the errors. This would also help in the management of the effects of the developmental differences in the pediatric patients.

The recommendations provided by the healthcare researchers should be considered to make the children of our nation safe from any form of threatening situations arising due to improper medication administration practices of the professionals. Creating a standard formulatory for that of the pediatric high risks as well as the commonly used medications should be achieved. Interventions for the standardized concentrations of the high-risk medications should be also followed. Initiatives should be taken for the reduction of the number of different types of available concentrations to that of the tiniest numbers possible (Nieman et al. 2015). Moreover, the professionals should provide recommended precalculated doses and measuring and recording weight in the kilograms only. Moreover, the professionals should be instructed in using the length-based dosing tools when the scale is found to be not available or when the use of these scales is not feasible. The organizational culture should be such that the authorities should be undertaking the promotion of the development of the distraction free safety zones of the medication for the preparations of medications. The higher authorities should also try to implement as well as the support the availability of the pharmacists in the emergency department ward. Moreover, the leaders should take the responsibility for the utilization of standardized order sets with the embedded best practice prescribing and dosing range maximums. The organizations should also include implementation and utilization of the CPOE and CDs with the pediatric-specific kilogram-only dosing guidelines and rules. This should include the upper dosing limits within the Emergency department information systems. The leaders within the ward should also encourage the community providers of the children with the medical complexity so that they can maintain a current medication list and an emergency information form to be available for the emergency care. The initiatives need to be taken for creating and integrating a dedicated pediatric medication safety curriculum into the training programs for the different healthcare professionals like the nurses, respiratory therapists, physicians, physician assistants, nurse practitioners, pre-hospital providers as well as pharmacists (lion et al. 2015). Actions should also be taken for the development of tools for the competency assessments of the professionals. The settings should also dispense the standardized delivery devices for the home administrations of liquid medications, dispensing of the millimeter only dosing of for the liquid medications that should be used in home. The leaders should also take the responsibilities for employing the advanced counseling such as the teach back procedures when sharing the medication instructions for the home use and should also use pictogram based dosing instruction sheets for the use of home medications.

From the above discussion, it becomes clear that pediatric patients are subjected to various kinds of threats in the emergency wards with the medication error being the most important occurrence that results in death of huge patients. The rate of death of child patients in the emergency ward had been thrice the number of deaths of adults in the emergency wards. Different types of issues result in such preventable deaths with the improper math calculation of the dose preparation mainly being the primary one. This might be because of the fact of improper math skills of the nurses or due to tremendous chaotic and tensed situation in the wards. It is also stated that many of the professionals are not expertise or they do not find enough pharmacists support while preparing the medication. Weight of the child is an important determining factor and many professionals do often not understand its relation with the dose preparation. Therefore, it is very important for the healthcare organizations to develop an organizational culture, which would be promoting the various alternatives, and initiatives of reducing such errors like introduction of technology, proper training, standardizing of concentrations and better access to reference materials and many others. This would help in reducing medication errors on the pediatric departments in the emergency wards.

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