Medication Errors Involving Children
In my medication error practice we have represented a number of children who have fallen victim to a medication error. These cases tend to be complex because small and sick children are usually less able to tolerate a wrong medication or an unintended overdose.
Our past legal case experience confirms the general evidence that children are more prone to medication error because most medications are formulated and prepared for adult usage. When a child is prescribed an "adult medication", the pharmacist must significant alter the dosage using a series of pediatric parameters. Obviously, when special preparation is required for a medication, the risk of medication error substantially increases.
While dosage mistakes represent a large portion of medication errors involving children, we have had several cases where the administration instructions on the label or insert information is incorrect. Again, most administration instructions are geared for adult use and therefore this is a fertile place for error.
Most pediatric medication errors are caused by performance neglect and carelessness in the preparation and delivery process. For example, pharmacy computer software safety alerts warning the pharmacist to take into account the age, weight, and medical history were either by-passed or ignored. Unfortunately, safety alert neglect is not uncommon in a busy retail pharmacy where a high number of prescriptions are being prepared in rapid order.
There is another note that deserves mention. Because child weight is a key factor in proper medication dosing, the child's present weight, in kilograms (kg) should be reflected on the pharmacy or medical records. Kilogram weight of the patient is required because the proper standard for prescription medication preparation is based on the metric system. However, if the weight of the child is reflected in pounds (lbs.), the possibility of medication error is increased because the patient's profile reflects a wrong weight.
Medication errors occur with children because full pharmacy and medical oversight is lacking. Safe dispensing of pediatric medications requires that every step of the medication delivery process is accounting for the special requirements of a child. When an error does occur, and the resulting case is properly handled, the valuable by-product is that the offending pharmacy or health-care facility will be far less likely to make a future pediatric error.
