• Alert
  • June 26, 2015

Pediatric Medication Concentration Standards With Retail Pharmacy

Patient Safety Alert

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

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.