new YORK (Reuters Health) – the use of drugs in
dose 10 times higher or lower than the indicated is a
threat to pediatric patients.
“Given that the rates quoted are of voluntary reports
“
and anonymous, unlike the existing error figures
“
physicians, is difficult to determine what the actual incidence”, said
Dr. Conor McDonnell, of the Hospital for sick children of
Toronto, Canada.
“Even so, I am not surprised to have found that amount of
“
dosing errors because pediatric patients are
“
especially exposed to such a risk”, he added.
Large variations in age, weight, dose and practices not
authorized favour the Commission of these errors, although few
studies had tried to identify them.
McDonnell and Catherine Doherty doctors analyzed the
errors in dosage that had identified reports
volunteers for five years to determine what classes of
drugs occurred more frequently and in what circumstances
these misdeeds.
252 Errors were recorded in the period 2004-2009, with the
(178 overdose and 74 subdosis) doses of 6,643 reports on
Security associated with the use of medications, which reveals a
upward trend. The average rate was 0,062 each 100
patient per day.
The most common errors occurred with the indication and the
Administration of drugs. Only 123 252 errors are
detected before they affect the patient.
Opioid analgesics were the pharmacological class with
which were committed more errors (18 per cent of all the
dosage errors), while morphine was the
only use more errors with medication (11 per cent of
all errors), followed by antimicrobials and in third
place, anticoagulants (exclusively heparin).
For these three classes of medicinal products, the origin
common error was in the calculation of the dose (44 cases)
and the incorrect administration device programming
(22 cases). The Elimination of the alarms and limits
suggested allowed that 25 of those mistakes were committed.
Opioids were the most reported drug class in
the 22 reports on damage to patients, while the
morphine was more specified medication.
“Despite the number of errors identified in the
“
study, no deaths were recorded or morbidities in the long
“
period”, said McDonnell.
With these results, the authors prepared a list with
more than two dozen recommendations to reduce the frequency
of errors in dosage in its Center.
McDonnell considered that “the most important factors still
“
being the recognition and identification of errors. “Not
all centres will commit the same mistake with them
drugs; therefore, it is important that centres
identify which medications are associated with errors and
local damage, and plan their interventions”.
“Having said that, opioids (notably morphine and
hydromorphone) are the drugs that most errors are
“
they are committed and take measures such as the use of fixed-dose sets
according to weight, clinical pharmacologists have of
guard, detect stress of clinical tasks and the
human factors (stress, distraction, fatigue) that favor the
appearance of these errors, like thus also take into account the
mistakes that can be made with intravenous administration
of opioids via the use of bombs, will reduce the frequency and
the results of medical errors associated with the
“
10 times greater or lesser drug dosage”,
added.
Source: Pediatrics, online April 2, 2012.
