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Joint Commission Alert: Prevent Pediatric Medication Errors
Date:4/11/2008

pediatric patients in kilograms, which then becomes the standardized weight used for prescriptions, medical records and staff communication;

-- Do not dispense or administer drugs classified as high risk until the patient has been weighed, unless it is an emergency situation;

-- Require prescribers to write out how they arrived at the proper dosage, as dose per weight, so that the calculation can be double checked by a pharmacist, nurse or both; and

-- Use pediatric-specific medication formulations and concentrations when possible.

The Alert also encourages organizations to be open and transparent if an error occurs in order to facilitate learning so that future errors can be prevented; drug manufacturers to develop pediatric-specific formulations and to standardize labeling and packaging of all medications; and parents to seek out information and ask questions about their child's medications and to repeat back instructions to health care professionals in order to avoid mix-ups.

The warning about pediatric medication errors is part of a series of Alerts issued by The Joint Commission. Information and guidance provided in these Alerts is drawn from The Joint Commission's Sentinel Event Database, a comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about adverse events and their underlying causes. Previous Alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides. The complete list and text of past issues of Sentinel Event Alert can be found on The Joint Commission website.

For more patient safety solutions, visit the Joint Commission International Center for Patient Safety's free, online database of practices and interventions to prevent adverse events at http://www.jcipatientsafety.org/.

Founded in 1951, The Joint C
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SOURCE The Joint Commission
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