Pediatric Dose Calculation Issues and the Need for Human Factors–Informed Preventative Technology Optimizations

Jacqueline Russell; Joanna Grimes; Sofia Teferi; Zoe Pruitt; Jessica Howe; Katharine Adams; Natasha Nicol; Seth Krevat; Deanna Busog; Raj Ratwani; Rebecca Jones; Ella Franklin

doi:10.33940/data/2022.6.5

journal article Open Access Jun 17, 2022

Pediatric Dose Calculation Issues and the Need for Human Factors–Informed Preventative Technology Optimizations

Jacqueline Russell Joanna Grimes

Natasha Nicol Seth Krevat Deanna Busog

Raj Ratwani Rebecca Jones

Ella Franklin

Patient Safety pp. 48-61 · Patient Safety Authority

View at Publisher Save 10.33940/data/2022.6.5

Abstract

Background: Dose calculation errors are one of the most common types of medication errors impacting children and they can result in significant harm. Technology-based solutions, such as computerized provider order entry, can effectively reduce dose calculation issues; however, these technologies are not always optimized, resulting in potential benefits not being fully realized.

Methods: We analyzed pediatric dose-related patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System using a task-analytic approach that focused on information being used in the dose calculation, calculation errors during ordering, and errors during dose preparation or administration. From these reports, we identified whether the patient was impacted by the error, the type of medication involved, and whether a technology optimization could have mitigated the issue.

Results: Of the 356 reports reviewed, 326 (91.6%) met the criteria for a dose calculation issue. The 326 reports meeting criteria had the following dose calculation issue types: wrong information used in the calculation (49 of 326, 15.0%), incorrect calculation during ordering (97 of 326, 29.8%), and calculated dose was not properly used or incorrect calculation during preparation/administration (180 of 326, 55.2%). Most of these dose calculation issues impacted the patient (219 of 326, 67.2%). Analysis of these issues by patient age group and drug class also revealed interesting patterns. Technology optimizations potentially could have addressed 81.6% of the dose calculation issues identified.

Conclusion: While many healthcare facilities have adopted health information technology and other devices to support the medication process, these technologies are not always optimized to address dose calculation issues. Human factors–informed recommendations, a safety checklist, and test cases for optimizing technology are provided in the context of these findings.

Topics

No keywords indexed for this article. Browse by subject →

References

36

[1]

The Joint Commission. Sentinel Event Alert 39: Preventing Pediatric Medication Errors. TJC website. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-39-preventing-pediatric-medication-errors. Updated April 14, 2021. Accessed April 21, 2022. 10.1097/01.bmsas.0000320104.74641.ff

[2]

Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of Pediatric Drug Calculation Errors by Prehospital Care Providers. Prehospital Emerg Care. 2008;12(4):486-494. doi:10.1080/10903120802290752 10.1080/10903120802290752

[3]

Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing Strategies for Preventing Medication Errors and Adverse Drug Events in Pediatric Inpatients. Am Acad Pediatr. Published 10.1542/peds.111.4.722

[4]

online 2003. Accessed December 8, 2021. https://pediatrics.aappublications.org/content/111/4/722.short

[5]

Wong ICK, Ghaleb MA, Franklin BD, Barber N. Incidence and Nature of Dosing Errors in Paediatric Medications. Drug Saf 2004 279. 2012;27(9):661-670. doi:10.2165/00002018-200427090-00004 10.2165/00002018-200427090-00004

[6]

Prevalence and Nature of Medication Errors and Preventable Adverse Drug Events in Paediatric and Neonatal Intensive Care Settings: A Systematic Review

Anwar A. Alghamdi, Richard N. Keers, Adam Sutherland et al.

Drug Safety 10.1007/s40264-019-00856-9

[7]

Conroy S, Sweis D, Planner C, et al. Interventions to Reduce Dosing Errors in Children: A Systematic Review of the Literature. Drug Saf. 2007;30(12):1111-1125. doi:10.2165/00002018-200730120-00004 10.2165/00002018-200730120-00004

[8]

Simonsen BO, Daehlin GK, Johansson I, Farup PG. Differences in Medication Knowledge and Risk of Errors Between Graduating Nursing Students and Working Registered Nurses: Comparative Study. BMC Health Serv Res. 2014;14(1). doi:10.1186/S12913-014-0580-7 10.1186/s12913-014-0580-7

[9]

Blais K, Bath JB. Drug Calculation Errors of Baccalaureate Nursing Students. Nurse Educ. 1992;17(1):12-15. doi:10.1097/00006223-199201000-00010 10.1097/00006223-199201000-00010

[10]

Gillham DM, Chu S. An Analysis of Student Nurses’ Medication Calculation Errors. Contemp Nurse. 1995;4(2):61-64. doi:10.5172/CONU.4.2.61 10.5172/conu.4.2.61

[11]

Lan Y, Wang K, Yu S, Chen I, Wu HW, Tang F. Medication Errors in Pediatric Nursing: Assessment of Nurses’ Knowledge and Analysis of the Consequences of Errors. Nurse Educ Today. 2014;34(5):821-828. doi: 10.1016/j.nedt.2013.07.019 10.1016/j.nedt.2013.07.019

[12]

Marufu T, Bower R, Hendron E, Manning J. Nursing Interventions to Reduce Medication Errors in Paediatrics and Neonates: Systematic Review and Meta-Analysis. J Pediatr Nurs. 2022;62:e139-e147. doi: 10.1016/j.pedn.2021.08.024 10.1016/j.pedn.2021.08.024

[13]

Eiland LS, Benner K, Gumpper KF, Heigham MK, Meyers R, Pham K, Potts AL. ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. J Pediatr Pharmacol Ther. 2018;23(3):177-191. doi: 10.5863/1551-6776-23.3.177 10.5863/1551-6776-23.3.177

[14]

Wang JK, Herzog NS, Kaushal R, Park C, Mochizuki C, Weingarten S. Prevention of Pediatric Medication Errors by Hospital Pharmacists and the Potential Benefit of Computerized Physician Order Entry. Pediatrics. 2007;119(1):e77-e85. doi:10.1542/peds.2006-0034 10.1542/peds.2006-0034

[15]

Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing Strategies for Preventing Medication Errors and Adverse Drug Events in Pediatric Inpatients. Pediatrics. 2003;111(4):722-729. doi:10.1542/PEDS.111.4.722 10.1542/peds.111.4.722

[16]

Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review

Magdalena Z Raban, Johanna I Westbrook

BMJ Quality & Safety 10.1136/bmjqs-2013-002118

[17]

Chongthavonsatit N, Kovavinthaweewat C, Yuksen C, et al. Comparison of Accuracy and Speed in Computer-Assisted Versus Conventional Methods for Pediatric Drug Dose Calculation: A Scenario-Based Randomized Controlled Trial. Glob Pediatr Heal. 2021;8. doi:10.1177/2333794X21999144 10.1177/2333794x21999144

[18]

The Prevalence of Dose Errors Among Paediatric Patients in Hospital Wards with and without Health Information Technology: A Systematic Review and Meta-Analysis

Peter J. Gates, Sophie A. Meyerson, Melissa T. Baysari et al.

Drug Safety 10.1007/s40264-018-0715-6

[19]

A usability and safety analysis of electronic health records: a multi-center study

Raj M Ratwani, Erica Savage, Amy Will et al.

Journal of the American Medical Informatics Associ... 10.1093/jamia/ocy088

[20]

Electronic Health Record Usability Issues and Potential Contribution to Patient Harm

Jessica L. Howe, Katharine T. Adams, A. Zachary Hettinger et al.

JAMA 10.1001/jama.2018.1171

[21]

Ratwani RM, Savage E, Will A, et al. Identifying Electronic Health Record Usability and Safety Challenges in Pediatric Settings. Health Aff. 2018;37(11). doi:10.1377/hlthaff.2018.0699 10.1377/hlthaff.2018.0699

[22]

Reason J. Understanding Adverse Events: Human Factors. BMJ Qual Saf. 1995;4:80-89. doi:10.1136/qshc.4.2.80 10.1136/qshc.4.2.80

[23]

Wickens C, Gordon S, Liu Y. An Introduction to Human Factors Engineering. Longman; 1998. https://archive.org/details/introductiontohu0000wick

[24]

Kirwan B. Human Error Identification Techniques for Risk Assessment of High Risk Systems—Part 1: Review and Evaluation of Techniques. Appl Ergon. 1998;29(3):157-177. http://www.ncbi.nlm.nih.gov/pubmed/9676333 10.1016/s0003-6870(98)00010-6

[25]

Identifying Health Information Technology Usability Issues Contributing to Medication Errors Across Medication Process Stages

Katharine T. Adams, Zoe Pruitt, Sadaf Kazi et al.

Journal of Patient Safety 10.1097/pts.0000000000000868

[26]

Kellogg KM, Hettinger Z, Shah M, et al. Our Current Approach to Root Cause Analysis: Is It Contributing to Our Failure to Improve Patient Safety? BMJ Qual Saf. 2017;26(5):381-387. doi:10.1136/BMJQS-2016-005991 10.1136/bmjqs-2016-005991

[27]

Pennsylvania Department of Health. Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002). DOH website. https://www.health.pa.gov/topics/Documents/Laws%20and%20Regulations/Act%2013%20of%202002.pdf. Published 2002. Accessed April 28, 2022 2022

[28]

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

Alissa L Russ, Alan J Zillich, Brittany L Melton et al.

Journal of the American Medical Informatics Associ... 10.1136/amiajnl-2013-002045

[29]

Kim GR, Lehmann CU, Simonian MM, et al. Pediatric Aspects of Inpatient Health Information Technology Systems. Pediatrics. 2008;122(6):e1287-e1296. doi:10.1542/PEDS.2008-2963 10.1542/peds.2008-2963

[30]

Joseph R, Lee SW, Anderson SV, Morrisette MJ. Impact of Interoperability of Smart Infusion Pumps and an Electronic Medical Record in Critical Care. Am J Heal Pharm. 2020;77(15):1231-1236. 10.1093/ajhp/zxaa164

[31]

Sittig DF, Ash JS, Singh H. SAFER Electron Health Rec Saf Assur Factors EHR Resil.; 2015. 10.1201/b18371

[32]

Chaparro JD, Classen DC, Danforth M, Stockwell DC, Longhurst CA. National Trends in Safety Performance of Electronic Health Record Systems in Children’s Hospitals. J Am Med Informatics Assoc. 2017;24(2):268-274. doi:10.1093/JAMIA/OCW134 10.1093/jamia/ocw134

[33]

Lowry SZ, Quinn MT, Ramaiah M, et al. (NISTIR 7865) A Human Factors Guide to Enhance EHR Usability of Critical User Interactions When Supporting Pediatric Patient Care.; 2012. 10.6028/nist.ir.7865

[34]

The Pew Charitable Trusts. Ways to Improve Electronic Health Record Safety. Pew website. https://www.pewtrusts.org/en/research-and-analysis/reports/2018/08/28/ways-to-improve-electronic-health-record-safety. Published August 28, 2018. Accessed April 21, 2022.

[35]

Institute for Safe Medication Practices. Guidelines for Standard Order Sets. ISMP website. https://www.ismp.org/guidelines/standard-order-sets. Published January 12, 2010. Accessed March 30, 2022.

[36]

Institute for Safe Medication Practices. Guidelines for Safe Electronic Communication of Medication Information. ISMP website. https://www.ismp.org/resources/guidelines-safe-electronic-communication-medication-information. Published January 16, 2019. Accessed March 30, 2022.

Metrics

8

Citations

36

References

Details

Published: Jun 17, 2022
Pages: 48-61
License: View

Authors

J

Jacqueline Russell