Caution: The Hospital May be Hazardous to Your Child's Health

It's my third and final year of being a pediatric resident. I'm the supervisor of the interns on the inpatient ward and we are at morning "x-ray rounds." My intern urgently grabs my arm, drags me to the back of the room and, ashen-faced, says "I think I just ordered 10 times the dose of insulin for Bobbi that I should have."

Let me explain. Because of her short stature, Bobbi is undergoing a "growth hormone stimulation test," in which we purposely give her a low dose of insulin to see if it will stimulate the normal production of growth hormone. Ten times the recommended dose will lead to dangerously low blood sugar levels which, among other things, could cause brain damage, even death to this happy, healthy, normal, short kid.

We race up three flights to the inpatient floor. I grab a syringe full of concentrated sugar (dextrose) and barge into her room where, to our great relief, she is chatting comfortably with her father, an attorney who - I am not making this up - sues doctors for malpractice.

I infuse her IV with the glucose, all the time asking her "How do you feel...How do you feel?"

"Anything wrong?" her father asks with just a touch of concern.

"Oh, no," I say, breezily. "Just a routine part of the test."

Having calculated the dose of sugar need to offset the overdose of insulin, she remains blessedly conscious and oblivious to my terror. Her blood sugar eventually dips only a little and the test is completed uneventfully.

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Scary. I still have nightmares about it, all these years later.

But, as a new article in the journal Pediatrics shows, apparently this is still not all that unusual. These researchers carefully looked at the medical records of kids admitted to 12 different Children's Hospitals. They found that about 7.3% (1 in 14 kids) experienced an "adverse drug effect" (ADE) of some sort - mostly a drug side effect. (By the way, the most common medications causing ADEs were pain killers (50%) and antibiotics. )

OK, 1 in 14 is a lot but before you panic, let's do the math:

1. Keep in mind that 13 of 14 (93%) had no reported problems of any kind with medications.


2. 97% of the ADEs were 'mild and temporary.'


3. Of the 7% who experienced an ADE, 1 in 5 was felt to have been "preventable."
   
4. That works out to 1 in 70 hospitalized children who will experience a medication error of some kind, which is way, way too high (and this probably underestimates the problem because some are never reported).
   
   

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Why do we make medication errors?

I could be flippant and say it's because we're human and that would be partly right. Also, I think it's easier to make a dosage error with children because the amount of medication given is often calculated on a "per weight" basis. That means the dose of a common medication could vary 50 fold between prescribing it for a 4 pound premature infant and a 200 pound teenager. So it's easier to get confused and harder to spot the error.

Additionally, there is the old "look alike/sound alike" mistake, whereby the pharmacist substitutes one medication (e.g., hydralazine) for another (hydroxyzine), either through my error or illegibility in writing it or the pharmacist's error in reading it.

But I've seen that most errors can be prevented by recognizing to err is human and by implementing appropriate safeguards to prevent us from screwing up. In my hospital, for example, all medication prescriptions are run through the computer to be sure the dose is in the usual range (and not, for example, the most common 'factor of 10 mistake' of my intern) and to warn of potential drug-drug interactions. Additionally, nurses check and double check that the dose ordered is the dose given, and that the right patient is getting the right meds.

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I'd like to empower you to play an active role in preventing medication errors to your (and others') children. Here's what you can do:

In the pediatric office:

1. Look at and review all prescriptions written by your pediatric provider.


2. Be sure the Rx is easily legible and clearly written.


3. Read it aloud to your pediatric provider.


4. Ask if the dose is the usual dose.


5. Ask your pediatric provider what hospital precautions are in place to prevent medication errors.

If your child is in the hospital:

1. Ask the staff the same question about procedures for preventing medication errors.


2. Look at all medications being administered to your child.


3. Be sure your child's name is on it.


4. Ask the nurse if the dose is the usual (if you're very ambitious check out all doses on the web to be sure they are in the normal range).

Will you be perceived as a pain in the butt by the medical staff? Absolutely, but, I hope, in a good way. After all, we all need to work together to ensure the inexcusable doesn't occur even one in a million times.

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Article cited:
"Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to Identify Medication-Related Harm in US Children's Hospitals"
Takata G, et al. Pediatrics, April 2008
http://pediatrics.aappublications.org/cgi/content/full/121/4/e927

Related Topics:

• WebMD Video: Fewer Perscription Errors
• WebMD Video: High Tech IV Pump to Catch Medical Errors

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