The ABCs of medication safety in paediatrics

One of the great things about children is the innocence with which they view the world.

Watch any of them in action and for the most part, they’re convinced they’re invincible. Cuts and scrapes don’t faze them; they only serve to slow them down until a band-aid is applied – out of sight, out of mind.

Few things can shatter a child’s notion of invincibility or strip them of their innocence like the health care system – especially when mistakes are made and permanent harm is done.

Paediatric patients present several unique challenges to health care providers. Due to wide ranges in height and weight along with fluid restrictions, best practices that work well for opioid infusions in adult patients do not transfer well to paediatric patients. The more variables there are, the greater the opportunity for error and harm.

It is recognized that while larger hospitals with dedicated paediatric units and specialized healthcare professionals are better able to cope with the challenges of treating paediatric patients, there are hundreds of smaller hospitals and health care organizations that do not have the dedicated paediatric resources and that are less familiar with the unique challenges of paediatric patients because fewer children come through their doors.

Given the potential for harm, the Canadian Association of Paediatric Health Centres (CAPHC) and the Institute for Safe Medication Practices Canada (ISMP Canada), with the support of the Canadian Patient Safety Institute (CPSI), have been working collaboratively to advance medication safety in paediatric health care settings.

Phase 1 of the project analyzed medication incident data from 11 Canadian paediatric hospitals with the goal of identifying the top medications reported as causing, or potentially causing, harm to patients, as well as the context in which these medication were causing harm. The results of phase one found that a handful of medications, opiates in particular, were responsible for a disproportionate number of patient safety incidents.

With that data collected, phase two focused on standardizing all processes involved in medication delivery, from physician order entry to the use of smart pumps with drug libraries. The goal of standardization is to remove ambiguity in the processes and to eliminate the need for nurses to perform calculations and prepare solutions for opioid infusions. It is has been demonstrated that through standardization and automation the opportunity for error is reduced, as the level of involvement of people has been reduced.

Phase two also included a human factors assessment of the introduction of standard concentrations of opioids in order to systematically consider the impact of the change. Although the introduction of standard concentrations is designed to address some of the gaps and challenges in the current process, it is possible that the change introduces new risks that might limit the effectiveness of the intervention.

The final phase of the project involves putting tools and resources in place, along with educational sessions and workshops, which will reduce the number of medication safety incidents. These include consensus guidelines for unique needs of community and paediatric tertiary hospitals including standard concentrations, administration, and storage and labeling. A Paediatric Opioid Safety Resource Kit with opioid infusion dosing charts, pre-preprinted orders, paediatric specific monographs and order guidelines and standards for communicating medication information is also being developed.

Tools such as these are a long time coming, especially in smaller health care organizations where dedicated paediatric resources are limited. CPSI is proud to support the efforts of CAPHC and ISMP Canada in providing these standardized resources.

For children who have been admitted to hospital, we not only hope to cure their illness, but to restore their sense of innocence and invincibility. Eliminating preventable and unnecessary harm by establishing standards around the administration of opioids in paediatric patients will go a long way towards accomplishing that goal.