Medication Dosing Errors Research Articles

Design of a Mixed-Reality Application to Reduce Pediatric Medication Errors in Prehospital Emergency Care

Children in prehospital emergency care are particularly vulnerable to medication errors, often with serious consequences. A prior study analyzing prehospital pediatric medication dosing errors, conducted after the implementation of a statewide pediatric drug-dosing reference for emergency medical services (EMS), identified an alarmingly high error rate. This significant finding led to the current study, which aims to develop technological interventions to reduce the frequency of medication errors for children during treatment by EMS. The current study focuses on the design and development of a safety strategy to automate medication administration using mixed-reality technology. Simulations were conducted to inform the design process, focusing on three scenarios: cardiac arrest, seizure, and burns. The design team included medical and engineering researchers, paramedics, and emergency medical technicians from multiple emergency medical service agencies. Root cause analysis (RCA) and failure mode and effects analysis (FMEA) were conducted after the simulations were completed. The RCA and FMEA were used to identify and prioritize failure points, which were then addressed in a mixed-reality solution using Microsoft HoloLens 2 to automate and enhance pediatric medication administration in prehospital emergency care. The resulting application will provide real-time assistance to guide paramedics through the complicated medication dosing and administration process using a detailed step-by-step guide, aiming to decrease medication errors and improve medication dosing accuracy.

Health Literacy–Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children

Inadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy-informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting. To test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children. This parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis. Permuted block (n = 4) randomization (1:1) to a health literacy-informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe). Observed dosing errors, assessed using a caregiver-submitted photograph of their child's medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment. Among 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P < .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P < .001). There were no differences in knowledge of medication name, indication, frequency, or storage. A health literacy-informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge. ClinicalTrials.gov Identifier: NCT05143047.

Analysis of a Medication Safety Intervention in the Pediatric Emergency Department

Strategies to reduce medication dosing errors are crucial for improving outcomes. The Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described. To describe implementation of MEDS in routine clinical practice and associated outcomes. This mixed-methods interrupted time series study of MEDS was conducted April 2021 to December 2022 in an academic pediatric ED using a hybrid type 1 design. Parents and guardians of children aged 90 days to 11.9 years who were discharged with acetaminophen, ibuprofen, or both were eligible for inclusion in the quantitative portion. Clinicians from a diversity of role groups (attending physician, resident, and nurse) were eligible for the qualitative portion. The study was conducted in 5 stages (baseline, intervention 1, washout, intervention 2, and sustainability phases). The 2 intervention phases taught clinical staff the MEDS intervention using different implementation strategies. During the intervention 1 phase, in-depth interviews were conducted until thematic saturation was reached; results were analyzed using thematic analysis. Interviews informed intervention 2 phase interventions. The primary outcome was any error (defined as dosing or frequency error) at a 48- to 72-hour follow-up phone call. There were 256 participants (median [IQR] child age, 1.7 [3.0-7.0] years; median [IQR] parent and guardian age, 36.0 [31.0-41.0] years; 200 females among parents and guardians [78.1%]) who consented and completed follow-up. At baseline, 44 of 68 participants (64.7%) made an error compared with 34 of 65 participants (52.3%) during intervention 1, 31 of 63 participants (49.X%) during intervention 2, and 34 of 60 participants (57.X%) during sustainability. After adjustment for language and health literacy, the adjusted odds ratio for error during the combined intervention phases was 0.52 (95% CI, 0.28-0.97) compared with baseline. This study found that both MEDS intervention phases were associated with decreased risk of error and that some improvement was sustained without active intervention. These findings suggest that attempts to develop simplified, brief interventions may be associated with improved medication safety for children after discharge from the ED.

Dose adjustment of rheumatology and allergy/immunology medications in chronic kidney disease: awareness and knowledge among internal medicine housestaff

Background Patients with chronic kidney disease (CKD) are at increased risk for adverse drug events due to medication dosing errors. We studied the awareness and knowledge among internal medicine housestaff (IMHS) of proper dose adjustment of commonly used rheumatology and allergy/immunology medications for patients with CKD. Methods We surveyed 353 IMHS to evaluate their awareness of the need for medication dose adjustments for patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate for common rheumatology and allergy/immunology medications. Results There was lack of awareness and knowledge for both rheumatology and allergy/immunology medications. Incorrect awareness and knowledge were as follows: allopurinol, 21.2%, 73.4%; colchicine, 19.0%, 75.9%; diphenhydramine, 34.0%, 34.0%; loratadine, 82.2%, 93.2%; and montelukast, 34.0%, 34.0%, respectively. Exploratory logistic regression analyses showed that PGY1 residents had higher odds for lack of awareness for allopurinol (odds ratio [OR] 24.57, 95% CI [confidence interval] 4.69, 99.13, P < 0.001), colchicine (OR 3.98, 95% CI 1.50, 10.51, P < 0.01), diphenhydramine (OR 2.24, 95% CI 1.10, 4.54, P < 0.04), and montelukast (OR 2.45, 95% CI 1.20, 5.00, P < 0.05) than PGY3 residents. A nephrology rotation in medical school was associated with lower odds for incorrect knowledge for allopurinol (OR 0.46, 95% CI 0.25, 0.87, P < 0.05) and montelukast (OR 0.50, 95% CI 0.27, 0.92, P < 0.05). Conclusion Overall, awareness and knowledge were poor among IMHS for dose adjustments of rheumatology and allergy/immunology medications in patients with CKD. Proper education and exposure to nephrology during training may improve quality and safety of care for patients with CKD.

Caregiver and Clinician Perspectives on Discharge Medication Counseling: A Qualitative Study.

Children are at increased risk for medication errors and the transition from hospital-to-home is a vulnerable time for errors to occur. This study aimed to explore the perspectives of multidisciplinary clinicians and caregivers regarding discharge medication counseling and to develop a conceptual model to inform intervention efforts to reduce discharge medication dosing errors. We conducted semistructured interviews with clinicians and caregivers of children <4 years old discharged from the hospital on a liquid medication. A hierarchical coding system was developed using the interview guide and several transcripts. Qualitative analysis employed an iterative inductive-deductive approach to identify domains and subthemes and inform a conceptual framework. We conducted focus groups and individual interviews with 17 caregivers and 16 clinicians. Using the Donabedian structure-process-outcomes model of quality evaluation, domains and subthemes included: (1) infrastructure of healthcare delivery, including supplies for counseling, content and organization of discharge instructions, clinician training and education, roles and responsibilities of team members, and hospital pharmacy delivery and counseling program; (2) processes of healthcare delivery, including medication reconciliation, counseling content, counseling techniques, and language barriers and health literacy; and (3) measurable outcomes, including medication dosing accuracy and caregiver understanding and adherence to discharge instructions. The conceptual model resulting from this analysis can be applied to the development and evaluation of interventions to reduce discharge medication dosing errors following a hospitalization. Interventions should use a health literacy universal precautions approach-written materials with plain language and pictures and verbal counseling with teach-back and show-back.

An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference

Background Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered. Objective To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference. Methods We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016–May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported. Results During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3–48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57–100.0]) and glucagon (3/4 or 75% [95% CI 32.57–100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04–91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47–76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36–60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19–67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19–67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64–36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31–5.98]). Conclusions Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.

PRESCRIPTION PATTERN OF ANTIBIOTICS AND THEIR APPROPRIATENESS IN PATIENTS WITH CHRONIC KIDNEY DISEASE-AN OBSERVATIONAL STUDY IN A TERTIARY CARE TEACHING HOSPITAL IN SOUTH INDIA

Objective: The primary objective of the study was to assess the prescribing pattern of antimicrobial agents in patients with chronic kidney disease. The secondary objectives of this study are to assess antibiotic appropriateness and dose optimization in patients with chronic kidney disease in relation to their comorbidities.&#x0D; Methods: A retrospective study was conducted, and medical records of all patients with CKD who were admitted in the nephrology department of Sri Venkateswara Institute of Medical Sciences, Tirupati, during Jan 2018-Dec 2018 were reviewed for antibiotic prescriptions. A total of 200 medical records were selected and assessed for antimicrobial prescriptions. A p-value &lt;0.05 was considered significant throughout the statistical analysis.&#x0D; Results: Analysis showed that overall 163 drugs were prescribed to CKD patients, of which nearly 96 (58.9%) required dosage adjustment. Of those 163 drugs, the majority N= 25 (26%), were unadjusted, and the remaining N = 71 (74%) were properly adjusted. The length of hospitalization of CKD patients was below 7 was 13.5%, above 7 was 86.5%. Mean and SD was 10.27±7.18 d, (Range: 1–35 d). The Chi-square analysis confirmed that out of the seven studied variables, two i.e. Length of stay days; p&lt;0.001.&#x0D; Conclusion: It is concluded that the occurrence of medication dosing errors was moderate in hospitalized chronic kidney disease patients in our study. Nearly 20% of patients who had prolonged stays were prescribed antibiotics for a prolonged period. The predictors of medication dosing errors in CKD patients were the severe-to-end stages of chronic kidney disease, the number of prescribed antibiotics, and the length of hospitalization.

Improving Caregiver Understanding of Liquid Acetaminophen Administration at Primary Care Visits

Liquid medication dosing errors are common in pediatrics. Our outpatient clinic identified gaps in caregiver education based on a 2015 American Academy of Pediatrics policy statement on prescribing liquid medications. This quality improvement (QI) initiative sought to improve caregiver's understanding of liquid acetaminophen administration at the 2-month well-child visit from 30% to 70% over a 32-month period. A resident-led interdisciplinary QI team performed sequential interventions to improve our outcome measure: the percentage of caregivers with an adequate understanding of 4 essential components of liquid acetaminophen administration (name, indication, dose, and frequency). Outcome data were collected via a 4-item verbal assessment of caregiver's understanding by nursing staff, with correct answers to all items considered adequate understanding. Process measures (medications prescribed and education provided), and balancing measures (anticipatory guidance items discussed) were gathered via electronic health record review. Shewhart "P" charts and established rules for detecting special cause variation were used to analyze data. Scatter plots assessed the association between the provision of syringes and caregiver understanding of medication administration. In 636 caregivers, overall understanding of medication use improved from 39.8% to 74%. Knowledge of accurate dosage improved from 50.9% to 76.8%. Correlation between syringe provision and caregiver understanding was strong (R = .84). Resident-led QI improved caregiver's understanding of liquid acetaminophen administration in infants. The most impactful interventions were implementation of English and Spanish pictograms and provision of dose-demarcated oral syringes, coupled with teach-back. Future interventions will examine generalizability to other medications and expansion to other services.

MO362: Braunschweig Body Composition, Butterfly Sonography and Drug Dosing in AKI Study (B3 D2 AKI––Study)

Abstract BACKGROUND AND AIMS In-hospital AKI is associated with increased morbidity and mortality. AKI Alert systems are frequently used to allow time detection of AKI patients based on changes in creatinine. We aimed to examine the hydration status, medication errors and prior existing CKD in a series of AKI 3 patients in a tertiary care hospital. METHOD Prospective single centre cohort study. Study was approved by the local IRB. Hydration status was assessed by Bioimpedance using the body composition monitor (Fresenius Medical Care). Renal size and exclusion of postrenal failure were accomplished using a point of care ultrasound system (Butterfly Network Inc.). Pharmacotherapy was entered into the Federal Medication Plan of Germany (Bundesmedikationsplan). RESULTS A total of 101 patients with AKI 3 were identified based on changes in creatinine only. The median (IQR) age was 74.0 (64.7–82.0) years with a BMI of 27.8 (23.5–34.2) kg/m2. The baseline creatinine of the patients was 1.53 (0.92–2.85) mg/dL. At the time of AKI 3 diagnosis the median [IQR] 4.1 (1.9–5.9) L. Systolic blood pressure was 116 (100–140) mmHg (Fig. 1). Median (IQR) kidney length was 10.4 (9.2–11.7) cm. Polypharmacy (&amp;gt; 5 drugs) was seen in 89.7% of all patients. Almost half of the patients (48.3%) received 10 or more drugs. A total of 38% of patients receiving an antibiotic received an inadequately high dose, followed by 7.8% receiving an inadequate dosing of oral antidiabetic drugs. CONCLUSION Patients detected by an AKI alert in a tertiary care hospital did mostly neither exhibit low blood pressure nor volume depletion. Postrenal AKI was undetected in 1 out of 101 patients. Medication dosing errors were frequently seen, especially in the dosing of antibiotics. A joined nephron-pharmacological approach seems to be important in patients with hospital acquired AKI 3.

Medication Dosing Error Leading to Potentially Lethal Methotrexate Toxicity

Pancytopenia is a rare consequence of rheumatoid arthritis treatment with low-dose methotrexate. Several literature reviews discovered earlier examples of severe pancytopenia caused by low- dose or dosage error of methotrexate. We discuss the case of a 67-year-old ACPA (Anti- citrullinated protein/peptide antibody) positive rheumatoid arthritis patient who had severe pancytopenia and oral mucositis as a result of methotrexate toxicity. To reduce medication dosing errors, we highlight its uncommon dose schedule.

Medication Dosing Error Leading to Potentially Lethal Methotrexate Toxicity

Pancytopenia is a rare consequence of rheumatoid arthritis treatment with low-dose methotrexate. Several literature reviews discovered earlier examples of severe pancytopenia caused by low- dose or dosage error of methotrexate. We discuss the case of a 67-year-old ACPA (Anti- citrullinated protein/peptide antibody) positive rheumatoid arthritis patient who had severe pancytopenia and oral mucositis as a result of methotrexate toxicity. To reduce medication dosing errors, we highlight its uncommon dose schedule.

The Effect of Documenting Patient Weight in Kilograms on Pediatric Medication Dosing Errors in Emergency Medical Services

Objectives: Up to 40% of children who receive a medication from emergency medical services (EMS) are subject to a dosing error. One of the reasons for this is difficulties adjusting dosages for weight. Converting weights from pounds to kilograms complicates this further. This is the rationale for the National EMS Quality Alliance measure Pediatrics-03b, which measures the proportion of children with a weight documented in kilograms. However, there is little evidence that this practice is associated with lower rates of dosing errors. Therefore, our objective was to determine whether EMS documentation of weight in kilograms was associated with a lower rate of pediatric medication dosing errors. Methods: We conducted a retrospective cross-sectional study of children 0-14 y/o in the 2016-17 electronic Maryland Emergency Medical Services Data System that received a weight-based medication. Using validated age-based formulas, we assigned a weight to patients without one documented. Doses were classified as errors and severe errors if they deviated from the state protocol by >20% or >50%, respectively. We compared the dosage errors in the two groups and completed secondary analyses for specific medications and age groups. Results: We identified 3,618 cases of medication administration, 53% of which had a documented weight. Patients with a documented weight had a significantly lower overall dose error rate than those without (22 vs. 26%, p<.05). A sensitivity analysis in which we assigned a weight to those patients with a weight recorded did not significantly change this result. Sub-analyses by individual medication showed that only epinephrine (34 vs. 56%, p<.05) and fentanyl (10 vs. 31%, p <.05) had significantly lower dosing error rates for patients with a documented weight. Infants were the only age group where documenting a weight was associated with a lower dosing error rate (33 vs. 53% p<.05). Conclusion: Our findings suggest that documenting a weight in kilograms is associated with a small but significantly lower rate of pediatric dosing errors by EMS. Documenting a weight in kilograms appears particularly important for specific medications and patient age groups. Additional strategies (including age-based standardized dosing) may be needed to further reduce pediatric dosing errors by EMS.

Identifying the pattern and risk factors for potential medication dosing errors in chronic renal impairment of critically ill patients

Purpose: Different prescription entries usually complicate the drug therapy for critically ill patients; therefore, we conducted this prospective study to assess the rates for appropriate renal dosing modifications in chronic kidney disease (CKD) patients admitted to the ICU and reported possible related factors of misadjustments. Design: We enrolled adult ICU patients who received at least one drug and experienced CKD with the estimated glomerular filtration rate (eGFR) ≤ of 59 ml/min on ICU admission. The latest Lexicomp drug information handbook recommendations were also applied as a standard guide for renal dosing changes. results: A total of 701 prescription entries were studied in 97 patients, and 13.8% (97 medications) required renal dose adjustment. Of the 97 drugs, 20.6% (20) had not been prescribed appropriately, according to eGFR. Antibiotics were the most likely medication group to require a dose adjustment and comprised the largest number of inappropriate prescriptions in our study. EGFR and the number of drugs that needed dose modification significantly affected renal dosing adjustment accuracy (p = 0.03 and 0.01, respectively). conclusion: These results revealed a high percentage of appropriate renal dose adjustment in ICU compared to other studies that evaluated non-critically ill patients. However, more attention should be paid to patients with a higher number of prescribed medicines for renal dose modification and lower eGFR to reduce medication errors.

Iatrogenic medication errors reported to the Victorian Poisons Information Centre.

Iatrogenic medication errors are a cause of medical morbidity and mortality. They result in significant cost to the Australian healthcare system each year. There is limited Australian evidence describing the iatrogenic errors occurring within the hospital system. To examine and describe iatrogenic medication errors occurring in Victorian healthcare settings through the analysis of referrals to a state Poisons Information Centre (PIC). A retrospective review of iatrogenic medication errors reported to the Victorian PIC (VPIC) from community and hospital healthcare settings from January 2015 to December 2019. Over a 5-year period, 357 iatrogenic errors were identified, 63% (n = 224) of which occurred in a hospital setting. The remaining errors occurred in a community healthcare setting. One in five patients were symptomatic from the medication error at the time of the call to the VPIC, and a change in management was required in 45% (n = 165) of all cases. Five percent (n = 17) of patients developed moderate to severe clinical toxicity as determined by the recorded poisoning severity score, and 88% (n = 18) of these required critical care management. Incorrect medication dosing accounted for 62% (n = 221) of errors. Common medication dosing errors included: double dose (51%, n = 114), incorrect medication administered (14%, n = 49), incorrect route (9%, n = 31), incorrect patient (6%, n = 22) and adult dose given to a child (4%, n = 15). Iatrogenic errors are occurring in the Victorian health care system. These errors can result in serious morbidity. Identification of causative factors and investment in preventative strategies will likely reduce associated morbidity and healthcare costs.

The effectiveness of EMR implementation regarding reducing documentation errors and waiting time for patients in outpatient clinics: a systematic review

Background: Electronic medical records (EMRs) refer to the digital copies of paper notes prepared in the physician’s office, outpatient clinics and other departments in health care institutes. EMRs are considered to be significant and preferable to paper records because they allow providers to keep accurate track of patient data and monitoring over time, thus reducing errors, and enhance overall health care quality. The aim of this systematic review was to highlight the significance of EMRs and the effectiveness of implementation regarding reducing documentation errors and waiting time for patients in outpatient clinics. Methods: PubMed, Central, Ovid, Scopus, Science Direct, Elsevier, Cochrane , WHO website and the McMaster University Health Evidence website from 2005-2020 were searched to identify studies that investigated the association between the EMR implementation and documentation error and waiting time for patients. A reviewer screened identified citations and extracted data according to the PRISMA guidelines and data was synthesized in a narrative manner. Results: After full text examination of the articles selected for this literature review, the major themes of relevance that were identified in the context of reducing documentation errors and waiting time for patients in outpatient clinic include: reduction of medical errors because of fewer documentation errors resulting from EMR implementation and reduction of waiting time for patients due to overall improvement of system workflow after use of EMRs. Conclusion: In summary of the reviewed evidence from published material, the implementation of an EMR system in any outpatient setting appears to reduce documentation errors (medication dose errors, issues of prescription errors). It was also seen that in many settings, waiting time for patients in outpatient clinics was reduced with EMR use, while in other settings it was not possible to determine if any significant improvement was seen in this aspect after EMR implementation.

281 The Impact of Documenting Patient Weight in Kilograms on Pediatric Medication Dosing Errors in Emergency Medical Services

Up to 40% of children who receive a medication from emergency medical services (EMS) are subject to a dosing error. The reasons for this are multifactorial but include difficulties adjusting drug dosages for patient weight. The conversion of patient weight from pounds to kilograms compounds this latent safety threat. In 2014 the National Highway Traffic Safety Administration launched the EMS Compass Project. One of three pediatric performance improvement measures was the proportion of children who received a weight-based medicine from EMS who had a weight documented in kilograms. This was also included in the initial National EMS Quality Alliance (NEMSQA) Measure Set. Despite inclusion in these benchmarks, there is little direct evidence that EMS documentation of a weight in kilograms is associated with lower rates of pediatric medication dosing errors. Our primary objective was to determine whether EMS documentation of a weight in kilograms was associated with a lower rate of pediatric medication dosing errors. We conducted a cross-sectional study using the 2016-17 Maryland state EMS database. We included all patients aged 0-14 years old who received a weight-based medication. Using validated age-based formulas, we assigned a weight (+/- 20% sensitivity margin) to patients who did not have one documented. Medication doses were classified as errors and severe errors if they deviated from the state protocol dose by > 20% or > 50% respectively. We used chi-squared tests to compare the proportion of medication dosage errors for children with and without a documented weight. We completed sub-analyses for the most commonly administered medications and by patient age group. We identified 3,618 eligible cases of medication administration. 1,927 (53%) of these records had a documented weight (Figure 1). Patients with a documented weight had a significantly lower overall rate of medication dosing errors when compared to those without (22 vs. 26%, p < .05) (Table 1). A sensitivity analysis where we assigned a weight to those patients with a weight recorded did not significantly change this result. Only epinephrine (34 vs. 56%, p < .05) and fentanyl (10 vs. 31%, p < .05) had significantly lower rates of medication dosing errors for patients with a documented weight. Infants had the highest rate of medication dosing errors. They were the only age group where documenting a weight was associated with a significantly lower dosing error rate (33% vs. 53%. P < .05) (Table 2). A limitation of our study is that we only had access to a limited dataset and could not analyze for confounding variables associated with dosing errors. Our overall rates of pediatric dosing error by EMS are lower than previously reported. Our findings suggest that documenting a weight in kilograms is associated with a small but significantly lower pediatric medication dosing errors rate. Our results show that documenting a weight in kilograms is particularly important for specific medications and patient age groups. Additional strategies (including age-based standardized dosing) may be needed to further reduce pediatric medication dosing errors by EMS.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A Standardized Formulary to Reduce Pediatric Medication Dosing Errors: A Mixed Methods Study

Objective: We hypothesized that implementation of a Medical Control Guideline (MCG) with a standardized formulary (fixed medication concentrations) and pre-calculated medication dosages in a large emergency medical services (EMS) system would reduce pediatric dosing errors. To assess the effectiveness of the standardized formulary to reduce errors, we chose to evaluate midazolam administration for seizures, because it is the most frequently dosed medication by EMS for children, and seizures are a time-sensitive condition. The objective of this study was to compare: 1) frequency of midazolam dosing errors during the field treatment of pediatric seizures and 2) paramedic anxiety and confidence in dosing midazolam for pediatric seizures, before and after implementation of the MCG. Methods: In this mixed-methods study, we utilized the Los Angeles County EMS data registry to identify pediatric patients ≤14 years-old treated with midazolam for seizure. We defined a dosing error as outside the dose directed by the color code on the length-based resuscitation tape, or ±20% the weight-based midazolam dose when color code was absent. We compared dosing errors during a two-year period before and after implementation of the MCG with the standardized formulary in February 2017. We surveyed paramedics to assess their level of anxiety and confidence in dosing midazolam and conducted semi-structured interviews with 20 respondents to further explore its impact on paramedic practice. Results: There were 80 dosing errors in 569 patients treated post-formulary (14.1%) compared with 92 dosing errors in 497 patients treated pre-formulary (18.5%), risk difference −4.5% (95% CI −8.9 to 0.0), p = 0.049. Among 304 paramedic survey respondents who had experience with the formulary, anxiety decreased (p < 0.001) and confidence increased (p < 0.001) post-formulary. Paramedics expressed the challenges of pediatric calls, the benefits of the MCG with the standardized formulary, and the ongoing challenges of pediatric medication dosing. Benefits included simplifying paramedic tasks, increasing paramedic self-efficacy, facilitating provider communication, and improving patient care. Conclusion: Implementation of a MCG with standardized formulary and pre-calculated medication dosing by weight reduced pediatric medication dosing errors and increased paramedic confidence in pediatric medication dosing. It may have the potential to facilitate patient care through improved communications and task simplification.

Can use of pictograms reduce liquid medication administration errors by mothers? An interventional study

BackgroundLiquid medication dosing errors (LMDE) made by caregivers affect treatment in children, but this is not a well-studied topic in many low-and middle-income countries including in India.MethodsAn intervention study was conducted among mothers attending a pediatric outpatient clinic of a tertiary care setting in Ujjain, India. The mothers randomly measured 12 volumes of a paracetamol liquid preparation by using a dropper (0.5 and 1 mL), measuring cup (2.5 and 5 mL), and calibrated spoon (2.5 and 5 mL) each with two instructions—oral-only measurement session (OMS) and oral plus pictogram measurement session (OPMS, the intervention). The main outcome was dosing error prevalence. The effectiveness of the intervention was assessed by measuring effect size. Risk factors for maximum LMDE were explored using backward multivariate logistic regression models. A P value of < 0.05 was considered statistically significant.ResultsIn total, 310 mothers [mean (± SD) age, 30.2 (± 4.18) years] were included. LMDE prevalence in the OMS versus OPMS for dropper 0.5 mL was 60% versus 48%; for l mL dropper was 63% versus 54%; for 2.5 mL cup 62% versus 54%; for 2.5 calibrated spoon 66% versus 59%; 5 mL cup 69% versus 57%; and 5 mL calibrated spoon 68% versus 55%. Comparing OMS with OPMS, underdosing was minimum with the calibrated spoon for 2.5 mL (OR 4.39) and maximum with the dropper for 1 mL (OR 9.40), and overdosing was minimum with the dropper for 0.5 mL (OR 7.12) and maximum with the calibrated spoon for 2.5 mL (OR 13.24). The effect size (dCohen) of the intervention OPMS was 1.86–6.4. Risk factors for the most prevalent dosing error, that is, with the calibrated spoon for 2.5 mL, were increasing age of the mother (aOR 1.08; P = 0.026) and nuclear family (aOR 2.83; P = 0.002). The risk of dosing errors decreased with higher education of the mothers.ConclusionsPictograms can effectively minimize LMDE even in less educated mothers.

Design, development, and deployment of an indication- and kidney function-based decision support tool to optimize treatment and reduce medication dosing errors.

Delivering clinical decision support (CDS) at the point of care has long been considered a major advantage of computerized physician order entry (CPOE). Despite the widespread implementation of CPOE, medication ordering errors and associated adverse events still occur at an unacceptable level. Previous attempts at indication- and kidney function-based dosing have mostly employed intrusive CDS, including interruptive alerts with poor usability. This descriptive work describes the design, development, and deployment of the Adult Dosing Methodology (ADM) module, a novel CDS tool that provides indication- and kidney-based dosing at the time of order entry. Inclusion of several antimicrobials in the initial set of medications allowed for the additional goal of optimizing therapy duration for appropriate antimicrobial stewardship. The CDS aims to decrease order entry errors and burden on providers by offering automatic dose and frequency recommendations, integration within the native electronic health record, and reasonable knowledge maintenance requirements. Following implementation, early utilization demonstrated high acceptance of automated recommendations, with up to 96% of provided automated recommendations accepted by users.

Assessment of Medication Dosage Adjustment in Hospitalized Patients With Chronic Kidney Disease.

BackgroundInappropriate medication dosing can cause adverse drug reactions or ineffective therapy due to declined renal function in patients with renal insufficiency. This necessitates proper renal dose adjustment. This study was proposed to evaluate medication dosage adjustment in hospitalized chronic kidney disease (CKD) patients.MethodsThis study included all CKD patients hospitalized between May 1, 2019, and April 25, 2020, at the Institute of Kidney Disease, Peshawar, Pakistan. The estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula, and dose appropriateness was established by evaluating practice with relevant reference books.ResultsOf the total 1,537 CKD patients, 231 (15.03%) had evidence of dosing error, which was considered for final analysis. Overall, 1,549 drugs were prescribed; 480 (30.99%) drugs required dose adjustment, of which 196 (40.42%) were adjusted properly and the remaining 286 (59.58%) were unadjusted. The most common unadjusted drugs were meropenem, cefepime, ciprofloxacin, and rosuvastatin, whereas captopril, aspirin, bisoprolol, pregabalin, and levofloxacin had the highest percentage of adjusted drugs. On multivariate logistic regression, the number of drugs requiring dosing adjustments and obstructive nephropathy were found to be statistically significant factors that increased the likelihood of the medication dosing errors: a unit increase in the number of drugs requiring dose adjustment increases 5.241 times the likelihood of dosing error. Similarly, the presence of obstructive nephropathy (OR: 0.383; 95% Cl: 0.153-0.960; p = 0.041) was found to be significantly associated with dosing error after adjustment for potential confounding factors.ConclusionThe dosing of more than half of the prescribed drugs that required adjustment in CKD patients was not adjusted, which showed that medication dosing errors were high. This highlights the importance of medication prescription according to guidelines in these patients to improve the outcomes of pharmacotherapy.