Pediatric Medication Concentration Standards With Retail Pharmacy

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
  • Michigan Pediatric Safety Collaborative on Compounded Oral Liquids

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.

For additional resources, contributors and sources, download the PDF.