Pediatric Medication Safety: Dispensing Medications

October 4, 2015
Matthew Grissinger, RPh, FISMP, FASCP

In an earlier blog, we started a discussion on strategies that should be in place for pediatric patients in hospitals. The survey included 14 error-prevention strategies encompassing the dispensing process. It is within this category that both the highest and lowest scoring error-prevention strategies were found.

For half of the strategies, at least 87% of respondents reported that they always (>99%) or almost always (90%-99%):

1)     use automated compounding devices to prepare PN/complex electrolyte solutions;

2)     enter PN/electrolyte solution orders into the pharmacy system and compounding software exactly as each ingredient is prescribed without needing unit conversions;

3)     enter/verify the patient’s weight in the pharmacy computer system before entering medication orders;

4)     verify the mg/kg or mg/m2 dose (or other basis for the dose) before preparing the medication;

5)     recalculate the patient’s dose before dispensing medications; and

6)     dispense patient-specific doses of liquid oral/enteral medications in cups or oral syringes.

Yet, full compliance with these strategies ranged between 63%-77%, leaving serious gaps in practice and room for improvement even with the highest scoring dispensing strategies.

For the two lowest scoring strategies, less than one-quarter of respondents reported full compliance. These low-scoring strategies were associated with having a clinical pharmacist present on patient care units, and having pharmacists who prepare parenteral solutions spend time in neonatal and pediatric units to observe prescribing and administration procedures. About one-quarter of respondents told us that these two strategies are never implemented in their practice areas. Pharmacists who spend time in clinical areas may have a better understanding of how physicians and nurses prescribe and administer medications, and may subsequently dispense medications in a ready-to-administer form, reducing manipulation of the drug on the unit and the risk of contamination or an error.    

For the next two lowest scoring strategies, only about half of respondents reported implementation at least 90% of the time, and only 40%-41% reported full compliance. These strategies included: 1) requiring a pharmacist to verify components of pediatric and neonatal compounded sterile preparations prior to adding to an admixture (syringe pull-back method not acceptable); and 2) employing barcode verification of ingredients during preparation of IV and oral liquid doses. Deficiencies in these pharmacy practices make it nearly impossible to detect a drug preparation and selection error because the applied label may still list the correct prescribed ingredient(s). Numerous harmful and fatal pediatric events have been reported to the Institute for Safe Medication Practices over the years, each with similar practice deficiencies.  

Similar to dose range checking capabilities with CPOE systems, only 57% of respondents said their pharmacy system consistently provided alerts about potentially incorrect doses; 7% reported that dose range checking was never available and/or enabled with their pharmacy systems. It is also concerning that all pharmacists/technicians who prepare pediatric parenteral solutions have not undergone specialized training and demonstrated competencies. Surprisingly, 10% of respondents reported that such training and competency validation never occurs, and another 6% indicated that it rarely takes place.

Does your organization employ any of the above strategies geared towards the dispensing of medications for the pediatric patients in your organization?


Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.