Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data

AORN Journal,  April, 2007  by Christopher H. Payne,  Christopher R. Smith,  Laura E. Newkirk,  Rodney W. Hicks

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In recent years, the occurrence of medication errors and their effect on the quality of patient care delivery has received national attention. Infants and children receiving postanesthesia care are at a significant risk for medication-related errors. The results of one study indicate that it is difficult to establish the true incidence of pediatric medication errors, but they may occur as frequently as one in every 20 medication orders.'

Astute practitioners intercept the majority of medication errors in the prescription and preparation (ie, early) phases of medication processing, but because fewer checks occur later in the medication process, fewer errors are intercepted during the administration phase. (2,3) Although the incidence of medication errors in the adult population is recognized to some extent, information regarding pediatric medication errors is lacking, especially about those that occur in the postanesthesia care unit (PACU). Information is available, however, about the general nature of pediatric medication errors that describes the risk for harmful events that occur. (4)

This article examines the known risks of pediatric medication errors in general and summarizes information about postanesthesia medication errors involving children. For the purposes of this article, children are defined as patients younger than 17 years of age. It is important to note, however, that adolescents should not be compared to infants or toddlers. The data for this analysis was obtained from MEDMARX, an Internet-accessible medication error reporting program operated by the United States Pharmacopeia (USP). (5)

BACKGROUND AND SIGNIFICANCE OF THE PROBLEM

It has been suggested that medication error reporting rates are as low as 5%. (6) If this is true, there is a dearth of information about the remaining 95% of errors. It is by way of medication error reporting and the knowledge gained from those reports that errors can be prevented. Health care personnel should routinely use the information gleaned from error reports involving children to improve the medication-use process. This knowledge is vital because children, particularly infants, are especially vulnerable to medication errors for a wide variety of reasons (eg, physiology, pharmacology, medication calculation).

PHYSIOLOGY AND PHARMACOLOGY. Pediatric patients are particularly vulnerable to medication errors because of the variation in weight, body surface, and organ maturity. (7) These factors ultimately affect their ability to absorb, distribute, metabolize, and excrete medications. In addition, children have fewer physiologic reserves to buffer a medication in the event of an accidental overdosed. (8)

Medication safety profiles typically are established using adult standards; thus, most medications are manufactured according to adult usage. (7) Additionally, few medications have been involved in clinical trials with children, so most lack for mal US Food and Drug Administration (FDA) licensing for use in the pediatric population. (9) Clear evidence exists that sources of prescribing errors include inadequate information regarding the effects of pharmacologic agents on small children. (7) The FDA estimates that more than 50% of newly approved medications each year are insufficiently tested among young children and, therefore, are not labeled for use in this population. (10) The results of another report indicate that nearly 75% of medications used for children have not been studied adequately for their effects on small children, despite federal legislation to encourage pediatric trials. (1) Health care providers thus have no clear indications for use and dosing guidelines. (11) Potentially effective therapy may be denied to many children, or providers may decide to prescribe a medication resulting in "off-label" use. (1) Although the term off-label may hold a negative connotation, it does not necessarily imply an improper procedure on the part of the prescriber. The prescriber often uses his or her knowledge of pharmacokinetics and pharmacodynamics and personal experience to use medications in an off-label manner.

PHARMACOKINETICS AND PHARMACODYNAMICS. The risk of medication errors occurring in children increases because data regarding pharmacokinetics, pharmacodynamics, and toxic profiles frequently are incomplete for the pediatric population. (7) Pharmacokinetics examines movement of medications through the body including absorption, distribution, metabolism, and excretion. A number of factors affecting the pharmacokinetic properties of a medication include obesity, disease processes, genetics, age, and gender of an individual. Pharmacodynamics refers to how the medication affects the individual. Cellular receptors take up the medication, which usually causes a biochemical reaction that changes the physiologic function of the cell or the cell's enzymes. Pharmacokinetic and pharmacodynamic properties vary widely for a pediatric patient. Immature hepatic, gastrointestinal, and kidney function can greatly influence a medication's bioavailability. Medications frequently are metabolized more rapidly in children than adults, but as a child's age advances toward puberty, metabolization becomes the same as that of an adult. (9)