Study Finds Small Doses of Drugs From Syringes Could Cause Medication Error in Children

As our Baltimore County pharmacy error attorneys discussed in a recent blog, according to a recent study by the Agency for Healthcare Research and Quality (AHRQ), medical errors are a leading cause of personal injury and death in this country, and rates for possible adverse drug events were three times higher with children than adults in hospitals, with an even higher rate for infants in intensive care units.

In a new study, published in the Canadian Medical Association Journal, a report found that preparing small medication dosages from syringes for infants and children can be dangerously inaccurate and cause medication dosing errors.

According to the report, in administering potent drugs to young patients, small doses are often prepared from medication stock of less than 0.1 milliliter (mL) in size, but the current equipment used to administer the drug does not allow for the correct and accurate measuring of drug volumes that are less than 0.1 mL.

Dr. Christopher Parshuram, the author of the study, who works in the University of Toronto’s Department of Pediatrics and directs the University of Toronto Center for Patient Safety’s Pediatric Patient Safety Research, stated that medications regularly requiring small doses include narcotics and sedatives that are extremely powerful, such as morphine and fentanyl—both drugs that as our Maryland medication error attorneys have reported in a recent blog, have a high-risk for medication mistakes which could lead to patient injury or wrongful death.

The report, according to Parshuram, indicates that with the administration of potent medications, there is a substantial source of medication dosing error affecting more than one-fourth of the infants and children studied. The report calls for a need to review the preparation methods, manufacturing processes and regulatory requirements in pediatric hospitals across North America, as this report found substantial evidence of medication errors, as preparing small doses of potent medication for children and infants is common.

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children, CMAJ, January 14, 2011
Preparing Small Doses of Medication From Syringes Called Risky, Bloomberg Businessweek, January 24, 2011

Related Web Resources:

Giving Medication to Children, The U.S. Food and Drug Administration

Agency for Healthcare Research and Quality, (AHRQ)

Institute for Safe Medication Practices, (ISMP)

Institute of Medicine, (IOM)

National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP)

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