Pediatric Medication Concentration Standards With Retail Pharmacy

Pediatric Medication Concentration Standards With Retail Pharmacy

Error in dosing concentration resulted in a patient being readmitted to the PICU for head imaging and observation.

Resultant harm to the patient

A patient required readmission to the PICU for head imaging and observation.

Actions to mitigate risk at your hospital

  • Create and use Enoxaparin prophylaxis and treatment order sets.
  • Implement prescriber education and communication.
  • Implement an alerting system (Pharmacy, Case Management, Quality, IT) that includes:
    • Dose range checking.
    • Review capability for all injectable medications.
    • Evaluation of missing concentrations.
  • Use a standardized concentration for Enoxaparin on all doses 100 mg or less.
  • Implement the use of whole numbers and rounding guidelines when ordering.
  • Standardize the type of prefilled syringes if possible.
    • Consider standardization for Enoxaparin doses under 40 mg with certain designated syringe (except for 30 mg dosages).
  • Engage Case Management and Home Health stakeholders in the review of orders prior to dispensing of custom compounded high-risk medications.
    • Standardize syringes used with non-prefilled doses.
  • Adopt other best practices for standardization and initiate state-wide collaborative initiatives for adoption.

Target audiences

  • Quality, patient safety, legal/risk management, cause analysis staff, organizational leaders, pharmacy leaders, home care, case management.

Fundamental issue

There was a deviation and systems failure leading to 10x dispensing error at home that reached the patient. A prescription was written as: Enoxaparin 0.6 ml (6mg) subcutaneous Q12 hours (inpatient standard concentration was 10mg/ml). It was dispensed as standard adult concentration of Enoxaparin (100mg/ml) to give 0.6ml subcutaneous Q12 hours, which equates to 60mg. This was a high-risk medication requiring a standardized process without similarly complex or standardized ordering, teaching or dispensing systems. There was a lack of communication and collaboration between inpatient and retail pharmacy.

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The Child Health Patient Safety Organization enables children’s hospitals to share safety event information and experiences to accelerate the elimination of preventable harm.