Stephanie Tupper considers it a good day on the job when nothing happens. As medication safety specialist at Cook Children’s Hospital in Fort Worth, Texas, she values “nothing happening” because it signifies no medication errors occurred.
Tupper uses her background as a clinical pharmacist to anticipate where errors may happen and works with hospital staff to establish solutions. Here, Tupper discusses challenges of ensuring pediatric patients receive the right medication and dosage in the hospital and at home when a parent or caregiver administers a drug.
What daily medication safety concerns do you address?
It’s really a balancing act. If we make a change for safety purposes, there will likely be downstream effects on our health care workers, which could then preclude them from doing something else. We must assess the entire process.
Our actions are often proactive, so it doesn’t feel like a big accomplishment because nothing happened. We must think our work may have prevented harm or even saved a child’s life had an error occurred.
How is medication safety different in pediatrics?
One of the biggest issues is many products we purchase are designed for adults. Dose patches are intended for adults, syringes are made to measure adult-sized volumes, and the computer systems are programmed for adult dosing.
A lot of errors could occur because many products are designed with adults in mind. It’s all our responsibilities to keep our patients safe. When an error happens, maybe a nurse administered the wrong drug volume, most often it’s not really that nurse’s fault.
We need to see how we can prevent that nurse from ever having to make that decision or be in the circumstance that lead to the error.
How are you addressing pediatric medication dosing?
We have several medications that require a very low dose, and the syringes on the market can’t measure that small of a volume. For example, we have to convert milliliter volume to units on an insulin syringe for a parent to administer.
There is a high risk of error in manual conversion calculation. I’ve joined the effort with Children’s Hospital Association to find a manufacturer that will produce lower-volume syringes. We are close to an agreement and hope in the near future the low-dose syringes are available to help staff and families give kids the medications they need and the concentrations are safe.
