Flipping the Script on Medication Errors

Flipping the Script on Medication Errors

Pharmacy teams are utilizing innovative approaches to prevent adverse drug effects.
A mother with infant consults a pharmacist.

Medications and their delivery systems are largely designed for adults. From syringes made to measure adult-sized volumes to computer systems programmed for adult dosing, children’s hospitals must account for many factors when giving medications to pediatric patients.

“Children’s bodies process medications differently than adults, so clinicians factor in the patient’s age as well as size when calculating doses. The process is complex and often includes additional steps to assure safe medication delivery,” says Terri Lyle Wilson, vice president of pharmacy at Children’s Hospital Association.

While it’s hard to quantify the exact number of pediatric medication errors, the US Pharmacopeia (USP) Medication Errors Reporting Program found higher rates of medication errors in pediatric patients (31%) than in adults (13%).

Medication errors are also among the most common events reported to the Child Health Patient Safety Organization® (PSO) by participating children’s hospitals. Between 2009 and 2022, medication errors accounted for 21% of safety events reported to the PSO. Of those, 13% resulted from the wrong dose; 4% from the wrong medication; 3% the wrong rate or time; and 1% the wrong route, patient or monitoring.

If an error harms a patient, it becomes an adverse drug event (ADE). “While not all medication errors cause an ADE, children’s hospitals’ pharmacy teams and clinicians work together to reduce or even eliminate preventable drug errors that could ultimately harm patients,” Wilson says.

Here’s a look at two children’s hospitals that are using out-of-the-box strategies to reduce medication errors.

Children’s National Hospital

To optimize operations and medication safety efforts, the pharmacy at Children’s National Hospital uses a multidisciplinary approach involving some nontraditional roles.

Several years ago, the team added a medical unit director. The physician—currently a hospitalist at Children’s National—bridges the gap between the pharmacy and providers. “I think every pharmacy struggles with getting physician buy-in to changes in practice,” said Sean Tan, Pharm.D., director of pharmacy of operations.

Tan says doctors who are accustomed to doing things a certain way may hesitate to adopt new workflows or procedures. “The medical unit director serves as a champion for pharmacy and can talk to providers as someone who is part of their world,” he says.

The medical unit director’s administrative time in the pharmacy is dedicated to medication management, protocol development and systems management, especially in relation to planned and unplanned downtimes and internal processes.

“For example, he makes sure the alerts that are firing are giving us the biggest bang for the buck. We don’t want people to get alert fatigue,” Tan says.

In 2023, the hospital’s pharmacy also added a quality control engineer to serve as a liaison between facilities and pharmacy operations.

Pharmacies must follow strict regulations, such as the United States Pharmacopeia Convention (USP) 797 that outlines compounding sterile drug preparation procedures. Local governments also have specific physical requirements for pharmacies.

For example, dedicated air handlers control the temperature, humidity, pressure differential and other factors in sterile cleanrooms where medications are compounded. If one must be taken online for repair or routine maintenance, the pharmacy will lose access to the cleanroom.

Having a quality control engineer on staff helps the pharmacy plan for preventive maintenance and manage outages. “We can make proactive contingency plans instead of reacting to an outside department saying, ‘We’re taking you down tomorrow,’” Tan says.

The engineer also manages construction projects, ensuring the pharmacy remains secure, infection control protocols are in place and changes to project blueprints won’t impact pharmacy operations.

Tan says the next step is adding an advanced practice nurse to the pharmacy team.

“The biggest user of our products and services is nursing, so we need to have a nurse on our team to bring that nursing perspective as we are making decisions,” he says.

Nationwide Children's

In 2009, Nationwide Children's set out to eliminate preventable patient harm, including ADEs.

Those efforts led to an 85% reduction in harmful medication events and helped the hospital maintain a low number of ADEs, despite increased safety event reports each year.

To move closer to zero ADEs, Nationwide Children’s expanded its focus. “We’ve started to introduce modern safety concepts into our medication safety work,” says Jenna Merandi, Pharm.D., MS, CPPS, medication safety officer at Nationwide Children’s. “Though we have made much improvement over the years, we are not at zero ADEs. We have been trying some new approaches that allow us to anticipate and respond in a proactive way while relentlessly searching for system weaknesses to make improvements.”

Proactive safety huddles help frontline staff plan for unique and complex situations. For example, if a provider orders diluted insulin, an uncommon practice at Nationwide Children’s, Merandi says the team identifies potential risks and designs a proactive safety plan. The team has collaborated with clinical informatics to build documentation in the electronic medical record that alerts all caregivers to the plan. Upwards of 300 proactive safety huddles have been held.

The medication safety team is co-led by a nurse, pharmacist and physician and includes medication safety pharmacists, patient safety strategists and nursing informatics. Along with proactive safety huddles, the team works to reduce ADEs by:

Holding “Learning Teams” where frontline staff learn and improve operational knowledge and build stronger safeguards in the system.

Spending time on the units understanding work-as-done to identify potential error traps and areas for improvement.

Performing medication safety huddles when harmful errors occur to better understand processes, challenges, and ways to prevent recurrence.

Working with informatics to design system improvements in the electronic medical record that make it “harder to do the wrong thing and easier to do the right thing.”

Since implementing a proactive approach in 2021, the hospital experienced its first centerline shift in 2022 after nearly eight years of maintaining essentially the same rate of ADEs.

“Working with frontline staff to continue to gain better understanding of what makes their work difficult, dangerous, or different and proactively implementing solutions, will help us to provide the safest care to our patients,” Merandi says.

This article has been amended and updated as the previous version contained erroneous information. Our apologies for the error.

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