The latest issue of The Joint Commission’s Sentinel Event Alert addresses the high risk for error medical care professionals face when administering adult medication formulations to children. The chance of miscalculation puts children at three times the risk of adverse drug reactions than adults.

The Alert also offers suggestions for improving the level of safety when giving adult medications to children, since this is the main source of errors involving pediatric medications, as tracked by the US Pharmacopeia.

Since children are often unable to describe or alert adults to adverse reactions, it is vitally important that healthcare providers maintain a very high level of diligence when formulating, administering, and monitoring children, especially when they’ve been given medications developed for adult use.

The Joint Commission has issued these suggestions:

• Follow the commission’s National Patient Safety Goals and Medication Management Standards for pediatric care
• Use only kilograms when weighing the patient to facilitate simplified and standardized record-keeping for communication, documentation, and formulating pediatric prescriptions
• Unless in the case of emergency, never administer drugs in the high-risk classification to children before they have been weighed in kilograms
• When calculating the formulations for pediatric prescriptions, always include the equations used in the calculations so they can be verified by caregivers throughout the system, from prescriber to nurse to pharmacist
• Whenever possible, limit children’s medications to pediatric formulations and concentrations instead of altering adult medications.

In addition, the commission encourages:

• Parents to research information, ask questions about pediatric prescriptions, and repeat dosing instructions to minimize errors at home
• Healthcare providers to maintain a transparent system of record-keeping so errors can be quickly identified and and investigated so future errors can be better prevented; and
• Pharmaceutical manufacturers to develop formulations in pediatric doses presented in standardized packages and uniform labeling.

The Joint Commission, headquartered in Oakbrook Terrace, Illinois, was founded in 1910 with the mission of continuous improvement of the safety and quality of medical care through accreditation and similar services that support performance and safety in healthcare facilities around the world.

Source: JCAHO