Protecting Hospitalized Children from Medication Errors

October 16, 2015
Matthew Grissinger, RPh, FISMP, FASCP

In the last blog, we started a discussion on strategies that should be in place for pediatric patients in hospitals. The survey included eight error-prevention strategies associated with the drug administration process.

For most of these strategies, more than 86% of respondents reported implementation at least 90% of the time. These strategies included:

1)     calculating patient-specific doses of emergency drugs and common medications and making them available for reference for each patient during hospitalization;

2)     providing nursing units with oral syringes that do not connect to IV tubing;

3)     using a smart infusion pump with an activated library to administer pediatric parenteral solutions that contain (or are) high-alert medications;

4)     requiring an independent double check before administering parenteral high-alert medications;

5)     using bedside barcode scanning systems for medications;

6)     tracing tubing lines from the solution to the patient (or vice versa) to verify line attachments before administration; and

7)     requiring nurses to undergo specialized training and demonstrate competency associated with pediatric medication administration.

Only 3% of respondents do not use smart pumps in any locations across all care areas for all high-alert medications. However, 35% reported partial compliance, perhaps suggesting that smart pumps are not used in all locations or that the drug library is not activated, diminishing the safety benefits of this technology. Independent double checks prior to administration of high-alert medications occurred consistently in only 65% of respondents’ practice sites, making this an unreliable strategy in the remaining 35% of respondents’ practice sites. Eleven percent of respondents have not implemented bedside barcode scanning with pediatric drug administration. 

The relatively simple strategy of tracing the line from the medication/solution source to the patient (or vice versa) to verify line attachment before drug administration only garnered full compliance by about half of the respondents, leaving patients at the remaining half of respondents’ practice sites exposed to the risk of life-threatening wrong route/wrong site errors and other types of errors. The lowest scoring strategy included the use of barcode scanning at the bedside to verify breast milk before each feeding. Despite the complexity associated with implementing this practice, almost half of all respondents (46%) for whom the strategy was applicable reported full compliance with this technology, and another 14% reported compliance 90%-99% of the time.

Does your organization employ any of the above strategies geared towards the administration 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.