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