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Dosing errors for cardiac medication most commonly reported in infants
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Cardiac medication errors in infants were reported most frequently by community hospitals, according to results of a study.
Results from CV medication error reports submitted to a voluntary, web- based medication error database from 2003-2004 indicated that children younger than 1 year accounted for 50% of total reported errors; 90% of those error reports occurred in infants younger than 6 months. Human error was cited in 74% of the 1,424 causes reported and improper dosing was the most frequent error type. No dosing errors were reported among children older than 6 years.
Human error was cited in 74% of the 1,424 causes reported, and improper dosing was the most frequent error type. Misinterpretation of patient weight, misinterpretation of orders, mathematical errors (including dilutional errors) and double or missed doses were common reasons for improper dosing.
The 607 error reports with age data revealed 4.1 years as the median age, and age distribution was not significantly different among facility types. Neonatal intensive care unit, general care unit, pediatric unit and inpatient pharmacy represented the most common sources of error reports. Most reported errors reached the patient but were not harmful, the researchers wrote.
The severity analysis showed 5% “near misses,” 91% errors without harm and 4% harmful errors with no fatalities.
The study results listed diuretics and antihypertensive as the most commonly reported drugs in improper dosing. Of the medications reported, nesiritide, calcium channel blockers, indomethacin, milrinone, digoxin and antiarrhythmic agents had the largest proportions of harmful reports. Differences in drug classes were not statistically significant.
Physicians prescribe diuretics and antihypertensive agents for pediatric patients with heart disease, but these drugs have the potential for more widespread use because of advances in neonatal care and the increasing incidence of childhood obesity and metabolic syndrome. Because of their frequent use, these drugs are considered by many to be safe. However, assessments of harm rates and cohorts of patients at particular risk would be beneficial information to clinicians, the researchers wrote.
The most frequently reported agents were consistent across all facility types and error locations, but community hospitals submitted the highest number of error reports. During the study period, 147 of the 616 reporting facilities submitted 821 CV medication error reports involving children; 71% were community hospitals, 18% were university hospitals, 4% were children’s hospitals and 7% represented other medical facilities.
Despite these percentages, the authors wrote that community hospitals accounted for fewer than the number of reports expected on the basis of their representation in the group, and university and children’s hospitals submitted more reports than expected (P=.03). Pharmacies with the most doses dispensed submitted the most error reports and hospitals with the most occupied beds reported more errors.
These differences were likely associated with more comprehensive error reporting infrastructures in larger hospitals with 24-hour pharmacies and in university facilities.
Alexander DC. Pediatrics. 2009;124:324-332.