Pediatric Medication Errors •  Public Health Emergency

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Pediatric Medication Errors • Public Health Emergency

By Elizabeth Hanink, RN, BSN, PHN
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Recently, the Joint Commission on Accreditation of Healthcare Organizations issued Sentinel Event Alert #39, “Preventing Pediatric Medication Errors.” Compiled in response to an occurrence which caused or has the potential to cause death or serious injury, these alerts are bulletins for facilities and healthcare professionals. They identify types of adverse events, examine the underlying causes, and suggest procedures to prevent future occurrences.

According to Alert #39, medication errors are probably the most common category of medical error. Pediatric dosing easily leads to mistakes because weight determines dose. Confusion persists about fractional measurements, such as mg. versus gm., as well as decimal use.

The Commission identifies four constants that contribute to the higher rate of medication errors for inpatient pediatric patients: drug formulations and packaging primarily target adults; the design of healthcare settings favors adults; very young children cannot communicate about adverse reactions; and children cannot tolerate physiologic trauma as well as adults.

Since the goal is to formulate strategies to prevent recurrences, #39 lists suggestions for limiting future errors. These include appropriate technology use, increased pharmacy oversight, and standardized medication labeling and administration. Other suggestions include stricter adherence to previous requirements, including use of the Commission’s official DO NOT USE abbreviations list, and timeliness in obtaining patient weights. JCAHO also stresses instructing caregivers with diligence.

The Commission notes that not all Sentinel Events are the result of error and not all errors become Sentinel Events. Still, nurses would do well to read the entire alert at      



Ever wait for respiratory therapy (RT) to come and adjust a ventilator or give a treatment? Usually, it’s no biggy. But sometimes waiting can cause distress.  Now magnify that situation in a public health emergency. How about an influenza pandemic or anthrax attack? You know what the patient needs and could almost do it yourself. Except you’re a nurse, not an RT.

The Agency for Healthcare Research and Quality (AHRQ), part of the Department of Health and Human Services, wants to help. Project XTREME is a cross-training initiative targeting healthcare professionals like nurses to provide basic respiratory care and ventilator management in disaster situations. The program consists of six modules covering infection control, terms and definitions, manual ventilation, mechanical ventilation (utilizing the models included in the federal government’s Strategic National Stockpile of medical supplies), airway maintenance, and airway suctioning.

A joint project of the AHRQ and the Denver Health Medical Center, the DVD includes interactive quizzes and an accompanying report on CD-ROM, “Project XTREME: Model for Health Professionals Cross-Training for Mass Casualty Respiratory Needs.” The report provides further information on the research and methods used in development, and the training model itself.

Get a free copy of the DVD/CD-ROM by email from or by calling 800-358-9295. Ask for AHRQ publication no. 07-0017.        

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