To reduce medication errors, emergency departments (EDs) should create a standard formulary for pediatric patients and use clinical decision support to optimize computerized physician order entry, the American Academy of Pediatrics (AAP) said in a policy statement.
This formulary should include pediatric high-risk and commonly used medications, concentrations of these high-risk medications should be standardized, and kilogram-only weight-based dosing should be used, reported Lee Benjamin, MD, and other members of the AAP Committee on Emergency Medicine.
EDs may also benefit from using pharmacist support, the authors, joined with colleagues from the American College of Emergency Physicians (ACEP) and the Emergency Nurses’ Association (ENA) Pediatric Emergency Medicine Committee, wrote in the document, which was published in Pediatrics and simultaneously in Annals of Emergency Medicine.
“Often, parents don’t or can’t bring their children into pediatric emergency departments,” ENA president Jeff Solheim, MSN, said in a statement. “In fact, the vast majority go to emergency departments in community hospitals, which may treat a low number of children. These new guidelines are recommended for all emergency departments and will improve care and reduce errors across the spectrum of acute care settings.”
The policy statement authors described the ED as a “high-risk environment” for medication errors for several reasons, including that there are “medically complex” patients there taking multiple medications that may be unknown to the ED staff, along with a lack of standard pediatric drug dosing and formulations, orders that are verbal, and an overall “hectic environment with frequent interruptions.”
While the authors said computerized order entry systems have reduced many errors, because they “obviate the need for simple dose calculation,” providers still override clinical decision support. One study, for example, reported override rates as high as 96%. The authors recommended the development of an override algorithm to “reduce user variability.”
When looking at a standardized formulary, Benjamin and co-authors noted that there are “currently no universally accepted, pediatric-specific standards with regard to dose suggestion and limits.” However, a standard formulary “will allow for consistent education” during initial training and continuing medication education for emergency providers, and will create “a consistent measure of provider competency.”
Medications that may be stocked in this formulary include limited concentrations and standard doses of frequently used medications, such as the following:
- Resuscitation medications
- Vasoactive infusions
- Look-alike and sound-alike medications
While the authors said they recommend measuring weight-based dosing, they advise “length-based dosing tools when a scale is unavailable or use is not feasible.”
In addition, Benjamin and colleagues recommend using support from dedicated pharmacists within EDs, noting that prior research indicates that many EDs lack consistent pharmacist coverage. But, the statement, notes, ACEP “supports the integration of pharmacists within the ED team,” and ENA supports the role of the emergency nurse and the staff to “efficiently complete the best possible medication histories and reduce medication discrepancies.”
And while future research is needed to assess how ED pharmacists may impact potential outcomes of medication safety and return on investment, “current experience reveals that there are improvements in medication safety when a pharmacist is present,” as well as cost savings of more than $1 million, according to a study of one single urban emergency department.
The statement authors also advocated for having training in pediatric medication safety as curricula in medical, nursing, and pharmacy schools — potentially from experts in pediatric emergency care from a multi-disciplinary panel. Graduate medical education level and pediatric and emergency medicine residency and fellowship programs “do not define specific requirements of pediatric medication training.”
In addition, while most of the recommendations focused on reducing prescribing errors, the writing team also touched on decreasing pediatric medication administration errors in the ED, including “using such strategies as standardizing the concentrations available for a given drug, having up-to-date reference materials, and using premixed intravenous preparations when possible.”
Benjamin et al also addressed language and health literary barriers that can affect ED medication safety in the home, suggesting use of strategies such as pictograms as part of discharge instructions. AAP also suggested that standardized delivery devices be distributed from the ED for use with these medications.
The American Academy of Pediatrics noted that all AAP policy statements automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
The authors disclosed no conflicts of interest.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner