Running head: INPATIENT PEDIATRIC
Inpatient Pediatric Medication Management
David LaBelle
Ferris State University
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INPATIENT PEDIATRIC
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Abstract
An important part of a nurse’s career is the administration of medication. While there are
several safety checks to help decrease the percentage of medication errors such as the five
rights (right patient, right route, right medication, right time, and right dose), errors still
can occur. Giving the correct dose of medication is especially important in the pediatric
population as many of the drugs are based on weight and small amounts of drugs are
administered (decimals may be used due to small doses) that further contribute to the
chance that an error could occur. By pinpointing the source of these errors, new
strategies could be implemented to reduce errors in medication administration.
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Pediatric Pain Management
Healthcare professionals must continually keep abreast of both current and new
medications. As nurses, one of our jobs is to safely administer medications that will
benefit the patient. Every nurse must be vigilant about staying educated. The nurse’s job
therefore, is to safely and effectively pass medications of all kinds, including pain
medication.
Introduction
More than three million children are treated as inpatients each year in a hospital.
Nearly all of them will require some type of medication during their stay. Medication
administration involves several steps and the involvement of several professional
practitioners. Typically, the physician orders the medication, the unit clerk transcribes
the order, pharmacy prepares the medication(s), and the nurse administers it.
Medication errors are possible with each of these steps and with each practitioner.
For example, the physician might order .5 mg of morphine for a two-year old but omits
the leading zero. The unit clerk reads the order as 5 mg and sends the order to pharmacy.
The nurse working has not worked in the pediatric ward before and administers 5 mg
instead of 0.5 mg. The child suffers severe respiratory depression and nearly dies.
Why is this topic so important? There are a higher percentage of medication
errors in the pediatric population with more potential to do harm. “For adults, the
reported incidence of errors in treatment with medication ranges from 1% to 30% of all
hospital admissions or 5% of orders written. In pediatrics however, this number has been
reported to be as high as 1 in 6.4 orders” (Committee on Drugs and Committee on
Hospital Care, 2003, p. 431).
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Assessment of Healthcare Environment
“A medication error is a failure in the treatment process that leads to, or has the
potential to lead to, harm to the patient” (Aronson, 2009, p. 513)
When one is reviewing medication errors, it is important to consider the hospital’s
policies in place regarding the administration of medications. Typically, most
practitioners will use the child’s “weight or body surface area, age, and clinical
condition” to calculate the correct dose of medication for that child (Kletsiou et el., 2014,
p. 2). It is an essential nursing skill to obtain an accurate height and weight on each
pediatric patient. By adhering to the hospital’s policy regarding what factors to use to
appropriately dose a child’s medication, it lessens the chance of making a medication
error. Nurses must know and adhere to the facilities policies when it comes to all aspects
of medication administration.
Another newer way to help reduce medication errors is computer charting rather
than paper charting. Computer charting eliminates trying to decipher handwritten orders,
making the chart accessible to all those involved in the patient’s care, and can provide
correct doses of a medication automatically. Understanding that not all hospitals utilize
computer charting, it must be noted that charting “varies according to the hospital policy”
(Gonzales, 2010, p. 556). Some hospital facilities recommend or even require paper
charting for certain situations, but will depend on the situation.
Quality and Safety
“Medication safety is a major concern and a global issue as regards the quality
and safety of patient care” (Chen et al., 2014, p. 822). Combining both facility policies
and resources will hopefully reduce the risk of medication errors. Patients are dependent
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upon nurses for ensuring their safety while being hospitalized. Patients expect and
deserve the utmost quality of care, especially as it pertains to this issue. Safe medication
administration will always be a concern to the practicing nurse and the five rights should
always be observed.
Challenges
One of the biggest challenges for nurses is minimizing human error when it
comes to administering mediation. Multiple resources and policies are available for
nurses to remind them the associated risks of medication administration error. These
resources include protocols, pharmacy department support, posters, and fellow nurses.
Another challenge that exists within the healthcare field of medication
administration is the common fear of overdosing a child with medication; especially pain
medication. This also causes concerns regarding under-medicating the patient for his or
her pain. It must be noted that within interdisciplinary approaches, physician’s pain
orders may be “insufficient to pre-medicate patients before procedures” (Czarnecki,
Hainsworth, Salamon, Thompson, 2014, p. 293.)
Understanding that the challenges of human errors are ongoing, one must consider
the background of each incident and why it is occurring. The nurse administering the
medication might get side-tracked, be extremely busy, or perhaps assume she or he has a
correct vial of medicine when in fact it is one that is very similar in appearance to what
he or she thinks.
It is easy to assume that pediatric patients require less medication as compared to
an adult. This is not always accurate. One must consider how the medication dosage is
calculated. The background of the patient must be taken into consideration also. Each
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patient tolerates medication differently and it should not be assumed that all pediatric
patients that are the same age and same weight will necessarily need the same dose.
Inferences, Implications, and Consequences
“While the emphasis on pharmacological knowledge and medication safety is
essential, equal importance should be given to system failures that impact patient safety.
Instructors should assist students to solve conflicts with staff nurses. Procedures for
medication preparation that are prone to errors should be discussed with administrators in
the clinical placements” (Lee, Lin, Lin, & Wu, 2014, p. 748).
When analyzing the literature, one can find that there are many sources
contributing to the issue of pediatric medication errors. There are studies that analyzed
student nurses, registered nurses, and physician’s pharmacological knowledge to try to
understand the source of the issue. One meta-analysis study found that out of six studies
researched, “9,167 drug administrations, the random effect error was 20.9%” (Kletsiou et
el., 2014, p. 9). If one calculates that rate of medication errors among pediatric patients
done in this study, that’s a total of 1,916 patients. It’s a difficult number to comprehend,
but hopefully implementing strategies and increasing the awareness of risks of
medication administration, can reduce errors in the pediatric population.
Further analyzing the research, other viewpoints concur that more pharmacy
education is necessary in nursing programs. A study concluded that, “evidence-based
results demonstrate that pediatric nurses have insufficient knowledge of pharmacology”
(Chen et al., 2014, p. 821). The study based this finding upon the insufficient education
of nurses after observing them in the clinical setting. The finding was also based on
improper use of double-checking medications with other registered nurses. However,
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this study failed to point out outliers contributing to medication errors. “Its disadvantage
is that it concentrates on human rather than systems sources of error” (Aronson, 2009, p.
515). One must consider the overall picture in pediatric medication errors rather than one
source. It is a collaborative issue that needs to be resolved and it is essential to discover
the sources.
Theory Base
Nursing Theorist
A nursing theorist whose research would be beneficial to help reduce pediatric
medication errors is Katharine Kolcaba. The theory that she researched is called the
Theory of Comfort and is defined as “the immediate experience of being strengthened
through having the needs for relief, ease, and transcendence met in four contexts of
experience (which are physical, psychospiritual, social, and environmental)” (Kolcaba,
2010).
From an interdisciplinary approach, pediatric pain management involves everyone
in the child’s care. That includes the, nurse, and any ancillary personnel. Each one of
these healthcare professionals has to be held accountable in managing the child’s pain
effectively and safely. According to Kolcaba, the need for relief (pain relief, for
example) is an expectation from the patient. By withholding medication or giving less
than the necessary amount because one doesn’t want to overdose the child could have
adverse effects. Yet many physicians today are still under medicating pediatric patients
for pain.
Communication is essential in preventing medication errors. “Communication
between the members of the multidisciplinary team regarding medication errors should
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be focused on adoption of common definitions for medical errors and their categories,
staff education in recognizing medication errors, and implementation of error reporting”
(Kletsiou et el., 2014, p. 11). By adopting these common definitions spoken about in the
journal, many errors could be avoided. Common definitions, for example, would be
including a leading zero in front of a decimal, standard abbreviations, etc. Common
definitions would definitely lead to much better communication between health
providers.
Non-Nursing Theorist
A non-nursing theorist that relates to managing pediatric pain before and after
surgery is Jerome Bruner. His theory of Discovery Learning is defined as when “the
learner draws on his or her own past experience and existing knowledge to discover facts
and relationships and new truths to be learned” (“Discovery Learning,” 2009).
From an interdisciplinary viewpoint relating to this theory, it takes the knowledge
and experience of everyone involved in the pediatric patient’s care to avoid medication
errors. For example, when a child undergoes a surgical procedure, pre-operatively, the
nurse is in charge of managing pain effectively and safely. In surgery, it’s the
anesthetist’s job to manage the patient’s pain, and post-operatively, that responsibility
returns to the nurse. Throughout this process, previous experience and knowledge is
utilized in assessing the pediatric patient’s safe dose of medication. Also, the physician
must be aware of the safe ranges of medication to administer in order to therapeutically
manage the child’s pain.
To reduce the risk of medication errors, the experience and knowledge of
everyone involved in the patient’s care must be fully utilized. By gathering this
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knowledge, medication errors can be reduced and hopefully avoided. This is true
especially for nurses as they are the most likely individuals to administer the medication.
Policies and guidelines need to be followed, especially when administering high-risk
medications such as heparin or insulin that when given in the wrong dose could
potentially be fatal. The knowledge that Bruner describes builds on previous experience
and exposures. The nurse with more experience and exposure to common pediatric
medications is less likely to error in the administration of medication than the nurse with
less experience and exposure to the pediatric population.
Recommendations for Quality and Safety
In recommending strategies to reduce the percentage of pediatric medication
errors, policies and interventions have been implemented by healthcare facilities.
Policies such as filling out incident reports have been implemented nationwide
throughout healthcare facilities. It must be noted that due to the fearful nature of
disciplinary procedures such as incident reports, “makes it difficult in detecting errors”
(Aronson, 2009, p. 516). Relating this idea back to Bruner’s theory of Discovery
Learning, a nurse would not be able to learn from retrospective incident reports unless he
or she is aware of the error and the consequence(s) of that error. Incident reports should
not be viewed as punishment but rather as a learning tool to prevent further errors of the
same kind. Incident reports are most helpful if nurses objectively fill out the report
whether it be regarding another nurse or themselves.
Another intervention that could be used to reduce the chances of making
medication errors in pediatrics is the use “computerized prescribing systems” (Aronson,
2009, p. 519). Having pre-drawn intravenous medication would reduce the risk of human
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error in administering medication. With technology becoming a growing industry within
the healthcare field, it isn’t unrealistic to imagine computers drawing up medications
instead of the nurse. But reliable equipment can always become faulty, which is why
continuous education for nurses must be in place regarding medications.
Lastly, another intervention that could be used is the application of the “nine
rights (adding four more rights: action, form, response, and documentation) instead of the
five rights for safer medication administration” (Lee, Lin, Lin, & Wu, 2014, p. 748).
American Nurses Association (ANA) Standards
There are three ANA standards that may be applied in the practice setting to
reduce pediatric medication errors. These standards are: education, communication, and
resource utilization (American Nurses Association, 2010, p. iv). Education is important
regarding the reduction of making a medication error. A nurse who is well versed in all
aspects of pediatric medication would be much less likely to commit a medication error
and if one does occur, will be more likely to know how to treat it. In nursing school, one
is taught that pediatrics is its own subcategory of patient care. Pediatric patients require
different dosages, approach, and assessment skills to provide effective care. When a
nurse is educated about medication administration, he or she is applying “skill
appropriate to the role, population, specialty, setting, or situation” (American Nurses
Association, 2010, p. 49).
The second standard that should be applied to practice is communication. The
standard of communication is described as when “the registered nurse communicates
effectively in a variety of formats in all areas of practice” (American Nurses Association,
2010, p. 54). When a nurse can communicate effectively amongst other health
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professionals and ask for reassurance, the nurse “improves the professional practice
environment and healthcare consumer outcomes” (American Nurses Association, 2010,
p. 56).
The third ANA standard that is related to this issue is resource utilization.
Resource utilization is defined as when “the registered nurse utilizes appropriate
resources to plan and provide nursing services that are safe, effective, and financially
responsible” (American Nurses Association, 2010, p. 60). In using the resources and
policies provided by the facility, medication errors can be reduced. With these resources,
the nurse identifies the “needs, potential for harm, and complexity of the task” with each
medication pass to their pediatric assignment. (American Nurses Association, 2010,
p.60).
Quality and Safety Education for Nurses (QSEN)
There are a total of six QSEN competencies: “patient-centered care, teamwork
and collaboration, evidence based practice, quality improvement, safety, and informatics”
(QSEN Institute, 2014). Two of these competencies can be directly applied to the issue
of pediatric medication. Those competencies are patient-centered care and safety.
The competency patient-centered care is applicable to the issue of pediatric
medication errors because the higher level of competence of the nurse in the field of
pediatrics, the lower the medication error rate will be. Pediatrics is a specialty that
demands specific skills of the nurse. Those skills may include being able to
communicate effectively, approaching care, or trustworthiness. Acquiring traits such as
these can only help the nurse develop a strong rapport with the child. With that
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establishment between the nurse and the pediatric patient, the nurse may be more familiar
of the child’s medication dosage thus reducing the risks for medication error.
The second QSEN competency of safety is the foundation to avoiding medication
errors in pediatrics. By abiding to safety precautions, policies, and resources, a nurse can
be competent in maintaining safety while passing medications. There are guidelines in
place and errors “can be prevented by the use of check-lists, fail-safe systems, and
computerized reminders” (Aronson, 2009, p. 516).
Conclusion
Pediatric medication errors are a concern within the nursing healthcare profession.
As a nurse, it is important to place safety nets around the pediatric patient when passing
medications. Safety nets to prevent such errors are available through hospital resources
and written policies, but as a nurse, one must implement them in practice. Using the
knowledge obtained, focusing on centered-patient care, and addressing the “nine rights”
of medication administration will hopefully reduce the chance of error in pediatric care
(Lee, Lin, Lin, & Wu, 2014, p. 748).
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References
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