Compounding errors linked to Pediatric Intensive Care Unit (PICU) admissions

July 25, 2018

Steps to prevent this from happening in your practice.

Recognizing that multiple compound formulations, sometimes known as recipes, may exist for a certain medication, it’s important to ensure you have the correct formulation (strength and dose) for your patient.

“In the last two years, I’ve been made aware of at least four cases of pediatric patients who have been admitted to the Pediatric Intensive Care Unit (PICU) due to suspected issues with compounded oral suspensions,” said Marcel Romanick, Clinical Practice Leader - North, Pharmacy Services, Alberta Health Services (AHS).

Part of the challenge is the lack of a widely available standard list of compound recipes. Some compounded medications commonly used and dispensed at children’s hospitals may not be as familiar to pharmacy professionals in the community.

After assessing the patient and discussing therapeutic options with the child’s parent or guardian, select compounding recipes that are evidence-based or considered a best practice or accepted clinical practice based on peer-reviewed literature. This information can be found in the primary literature, from practice guidelines or from a reputable source such as a compounding manual published by a children’s hospital.

“Our drug information group within Alberta Health Services reviews recipes before we add them to our database. If you get a prescription for a pediatric patient and you don’t have a recipe for it, please call the Stollery or Alberta Children’s Hospital and ask to speak to a pharmacist,” said Marcel.

In addition, you can call the Poison and Drug Information Service (PADIS) for recipes. Operated by AHS, the service is free, confidential, and available 24/7.

“Making sure you have a standard process for reviewing, validating, and documenting recipes is a crucial step in reducing compounding errors. It’s also important to have a process for double-checking your calculations to ensure correct strength and dose,” said Shao Lee, Professional Practice Director, Alberta College of Pharmacy. “Review current processes regularly to identify possible gaps and work with your team to make improvements as needed.”

“Another challenge is the time it takes to prepare a compound, especially when a parent is in front of you with an upset child and they are in a hurry to pick up their medication as a result. Explaining that their child’s medication must be individually prepared onsite, and your priority is to ensure the medication is prepared properly so it is safe and effective, they will likely help them understand the wait,” said Marcel.

“You can also speak to the parent or guardian about the importance of using oral syringes and how to measure correctly," added Marcel. "It’s a great way to ensure that the dose (volume) they were taking matches the dose (volume) you are suggesting they take with the newly compounded formulation. This helps identify a potential discrepancy in formulation concentration."

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