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

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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About the PSO

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