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Survey Results Reveal Gaps in Medication Safety

September 11, 2015

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

A large number of respondents (85%) reported that, at least 90% of the time, their organizations require: 1) the use of metric doses when ordering pediatric liquid medications; and 2) the entry/verification of the patient’s weight in the computerized prescriber order entry (CPOE) system before entering medication orders. The remaining respondents reported implementation of these practices less consistently, which could lead to serious dosing errors. 

Dose range checking software was always available and enabled to provide alerts to prescribers about unsafe doses in only 61% of the respondents’ CPOE systems; 7% reported that dose range checking was never available and/or enabled with their CPOE systems. For the remaining 32% of respondents, the dose checking capabilities appear to be inconsistent.

Two other prescribing strategies involved parenteral nutrition (PN) or other complex electrolyte solutions. On units where these products were prescribed, only 64% of respondents reported that prescribers always ordered each ingredient as weight/kg/day for younger children, and 53% reported that prescribers always ordered each ingredient per day for older children. Using variable units of measure and ways of expressing doses when prescribing PN or electrolyte ingredients could be a source of serious errors.  

Surprisingly, the lowest scoring error-prevention strategy requires minimal prescriber effort and is one that ISMP has long endorsed: including the mg/kg, mg/m2, or other basis for the dose and the calculated amount per dose with pediatric drug orders. In the survey, we allowed exceptions for drugs that do not lend themselves to weight-based dosing. Despite this, only 37% of respondents reported full compliance with the strategy. Another 27% reported implementation of the strategy for 90%-99% of applicable orders. The remaining 36% of respondents reported inconsistent practices, making it difficult for pharmacists and nurses to verify the patient’s dose and detect a prescribing error.

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


The views expressed on this blog are solely those of the author and do not necessarily reflect the views of Pharmacy Learning Network or other Pharmacy Learning Network authors. Blog entries are not medical advice.

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