Pediatric Medication Safety in Emergency Department

This article discusses the factors contributing to medication errors in pediatric emergency departments and interventions to develop a safe environment. It highlights the importance of computerized physician order entry, standardized concentrations, and increasing knowledge support. The article also emphasizes the need for a blame-free reporting system and a patient-centered approach to improve medication safety.

Running head: PEDIATRIC MEDICATION SAFETY IN EMERGENCY DEPARTMENT
PEDIATRIC MEDICATION SAFETY IN EMERGENCY DEPARTMENT
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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

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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.
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).

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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.
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

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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).

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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

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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 settings. 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

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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

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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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References:
Beaudoin, F.L., Merchant, R.C., Janicki, A., McKaig, D.M. and Babu, K.M., 2015. Preventing
iatrogenic overdose: a review of in–emergency department opioid-related adverse drug events
and medication errors. Annals of emergency medicine, 65(4), pp.423-431.
Bogner, M.S., 2018. Human error in medicine. CRC Press.
Cohen, C., King, A., Lin, C.P., Friedman, G.K., Monroe, K. and Kutny, M., 2016. Protocol for
reducing time to antibiotics in pediatric patients presenting to an emergency department with
fever and neutropenia: efficacy and barriers. Pediatric emergency care, 32(11), pp.739-745.
Dayal, P., Hojman, N.M., Kissee, J.L., Evans, J., Natale, J.E., Huang, Y., Litman, R.L., Nesbitt,
T.S. and Marcin, J.P., 2016. Impact of telemedicine on severity of illness and outcomes among
children transferred from referring emergency departments to a children’s hospital
PICU. Pediatric Critical Care Medicine, 17(6), pp.516-521.
Goldman, M.P., Wong, A.H., Bhatnagar, A., Emerson, B.L., Brown, L.L. and Auerbach, M.A.,
2018. Providers’ perceptions of caring for pediatric patients in community hospital emergency
departments: a mixed methods analysis. Academic Emergency Medicine.
Guise, J.M., Meckler, G., O'brien, K., Curry, M., Engle, P., Dickinson, C., Dickinson, K.,
Hansen, M. and Lambert, W., 2015. Patient safety perceptions in pediatric out-of-hospital
emergency care: children's safety initiative. The Journal of pediatrics, 167(5), pp.1143-1148.
Hansen, M., Meckler, G., Dickinson, C., Dickenson, K., Jui, J., Lambert, W. and Guise, J.M.,
2015. Children's safety initiative: a national assessment of pediatric educational needs among
emergency medical services providers. Prehospital Emergency Care, 19(2), pp.287-291.

10
PEDIATRIC MEDICATION SAFETY IN EMERGENCY DEPARTMENT
Lion, K.C., Brown, J.C., Ebel, B.E., Klein, E.J., Strelitz, B., Gutman, C.K., Hencz, P.,
Fernandez, J. and Mangione-Smith, R., 2015. Effect of telephone vs video interpretation on
parent comprehension, communication, and utilization in the pediatric emergency department: a
randomized clinical trial. JAMA pediatrics, 169(12), pp.1117-1125.
Lovegrove, M.C., Weidle, N.J. and Budnitz, D.S., 2015. Trends in emergency department visits
for unsupervised pediatric medication exposures, 2004–2013. Pediatrics, pp.peds-2015.
McDonald, D., Mansukhani, R., Kokotajlo, S., Diaz, F. and Robinson, C., 2018. Effect of
Nursing Education on Optimization of Medication Reconciliation in the Pediatric Emergency
Department. The Journal of Pediatric Pharmacology and Therapeutics, 23(3), pp.203-208.
Moreira, M.E., Hernandez, C., Stevens, A.D., Jones, S., Sande, M., Blumen, J.R., Hopkins, E.,
Bakes, K. and Haukoos, J.S., 2015. Color-coded prefilled medication syringes decrease time to
delivery and dosing error in simulated emergency department pediatric resuscitations. Annals of
emergency medicine, 66(2), pp.97-106.
Neuss, M.N., Gilmore, T.R., Belderson, K.M., Billett, A.L., Conti-Kalchik, T., Harvey, B.E.,
Hendricks, C., LeFebvre, K.B., Mangu, P.B., McNiff, K. and Olsen, M., 2016. 2016 updated
American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration
safety standards, including standards for pediatric oncology. Journal of oncology
practice, 12(12), pp.1262-1271.
Niemann, D., Bertsche, A., Meyrath, D., Koepf, E.D., Traiser, C., Seebald, K., Schmitt, C.P.,
Hoffmann, G.F., Haefeli, W.E. and Bertsche, T., 2015. A prospective three‐step intervention
study to prevent medication errors in drug handling in paediatric care. Journal of clinical
nursing, 24(1-2), pp.101-114.
Patton, L.J., Tidwell, J.D., Falder-Saeed, K.L., Young, V.B., Lewis, B.D. and Binder, J.F., 2017.
Ensuring safe transfer of pediatric patients: a quality improvement project to standardize handoff
communication. Journal of pediatric nursing, 34, pp.44-52.
Rees, P., Edwards, A., Powell, C., Hibbert, P., Williams, H., Makeham, M., Carter, B., Luff, D.,
Parry, G., Avery, A. and Sheikh, A., 2017. Patient safety incidents involving sick children in

11
PEDIATRIC MEDICATION SAFETY IN EMERGENCY DEPARTMENT
primary care in England and Wales: a mixed methods analysis. PLoS medicine, 14(1),
p.e1002217.
Rinke, M.L., Bundy, D.G., Velasquez, C.A., Rao, S., Zerhouni, Y., Lobner, K., Blanck, J.F. and
Miller, M.R., 2014. Interventions to reduce pediatric medication errors: a systematic
review. Pediatrics, pp.peds-2013.
Ruddy, R.M., Chamberlain, J.M., Mahajan, P.V., Funai, T., O'Connell, K.J., Blumberg, S.,
Lichenstein, R., Gramse, H.L., Shaw, K.N. and Pediatric Emergency Care Applied Research
Network, 2015. Near misses and unsafe conditions reported in a Pediatric Emergency Research
Network. BMJ open, 5(9), p.e007541.
Schumacher, D.J., Holmboe, E.S., van der Vleuten, C., Busari, J.O. and Carraccio, C., 2018.
Developing resident-sensitive quality measures: A model from pediatric emergency
medicine. Academic Medicine, 93(7), pp.1071-1078.
Sethuraman, U., Kannikeswaran, N., Murray, K.P., Zidan, M.A. and Chamberlain, J.M., 2015.
Prescription errors before and after introduction of electronic medication alert system in a
pediatric emergency department. Academic Emergency Medicine, 22(6), pp.714-719.
Siebert, J.N., Ehrler, F., Combescure, C., Lacroix, L., Haddad, K., Sanchez, O., Gervaix, A.,
Lovis, C. and Manzano, S., 2017. A mobile device app to reduce time to drug delivery and
medication errors during simulated pediatric cardiopulmonary resuscitation: a randomized
controlled trial. Journal of medical Internet research, 19(2).
Stevens, A.D., Hernandez, C., Jones, S., Moreira, M.E., Blumen, J.R., Hopkins, E., Sande, M.,
Bakes, K. and Haukoos, J.S., 2015. Color-coded prefilled medication syringes decrease time to
delivery and dosing errors in simulated prehospital pediatric resuscitations: a randomized
crossover trial. Resuscitation, 96, pp.85-91.
Tanner, D., Negaard, A., Huang, R., Evans, N. and Hennes, H., 2017. A prospective evaluation
of the accuracy of weight estimation using the broselow tape in overweight and obese pediatric
patients in the emergency department. Pediatric emergency care, 33(10), pp.675-678.