Improving pediatric medication safety

September 21, 2022

A multi-incident analysis reveals themes contributing to pediatric medication errors and tips to prevent future incidents.

The Institute for Safe Medication Practices Canada recently completed a multi-incident analysis of harmful medication incidents involving pediatric patients in the community. A multi-incident analysis is one way to look at a few medication incidents and quantify the information available to identify contributing factors and develop safety measures to prevent reoccurrence. This analysis identified opportunities to improve pediatric medication safety.

The analysis identified numerous factors contributing to medication errors, which were broken down into three main themes:

  • inaccessible pediatric-specific resources and products, such as
    • information and knowledge gaps about medication incidents and/or doses for pediatric patients, and
    • off-label use and lack of products suitable for administration to pediatric patients;
  • communication gaps
    • between members of the healthcare team,
    • between healthcare providers and caregivers, and
    • between caregivers and children; and
  • product preparation vulnerabilities, including
    • lack of independent double checks, and
    • problems relating to compounding process.

The analysis includes tips to address these factors, including

  • complete an independent calculation to confirm the prescribed dose;
  • verify supporting evidence for pediatric off-label use;
  • have conversations with patients and families about medications, including when to follow up with the prescriber;
  • do an independent double check of every calculation performed and final amounts including during product preparation; and
  • confirm the prescribed dose by checking a reliable pediatric resource.

For the complete multi-incident analysis report, refer to the ISMP Canada Safety Bulletin (Volume 22, Issue 5).


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