Physician and Nurse Burn – Out – Part XX. Mistakes in Children’s Medications

– “For a nurse, nothing compares to a screw-up in a kid’s medication —period.”

Louise X. is a veteran and proficient nurse that works in the Oncology ward of a large South Florida public hospital, who almost harmed an admitted child when she wrongly calculated the dilution parameters of a medication that comes in adult dosage from the manufacturer and must be adapted to lower children’s dosages. It was early dawn, and she was about to finish her nightly shift with a last round of medications for the admitted patients. The fatal error could have hurt the patient but providentially there is a protocol of double check up of these dosages in her hospital. An on-duty pharmacist picked up the mistake and quickly called her to correct it.

Note. This reproduction of a World War II US Army’s recruiting poster was taken from Wikimedia Commons.

Medication errors are frequent in all medical institutions worldwide. The National Coordinating Council for Medication Error Reporting and Prevention defines them as: “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education, monitoring; and use.” Traditionally Nursing Schools have taught their students to follow the Five Rights rule in their practices:

1. Right patient.
2. Right Drug.
3. Right dose.
4. Right route.
5. Right Time.

Some reviews claim medical errors in the USA range from less than 0.2% to a whooping 10% of all prescriptions, which is difficult to determine due to under or wrong reporting; a serious study across the whole health care spectrum is needed.

Not only the nursing personnel that administers the medication is to blame but we, physicians, have a fair share of blame as we should avoid these common mistakes:

1. We should avoid the use of confusing symbols like “U” and write the full name “Units” instead.
2. We should avoid the abbreviations and acronyms and write the full name.
3. We should not determine the frequency with complex signs like QD. QOD or QID, but rather spell it clearly with common vocabulary.
4. We should not use zeros before or after a number.
5. We should not use any abbreviations for the medications’

There should be sound prescribing policies in al major health care institutions like:

1. Drug reference material should be available online to care personnel.
2. Basic clinical information like age, weight, allergies, etc., should be clear.
3. If a physician’s order is unclear, incomplete, or illegible, it should be clarified.
4. Dispense single-dose vials and ampules, avoiding multidose vials.
5. Whenever possible, prefer oral administration rather than parenteral routes.
6. Avoid distracting activities like texting when you do the medication rounds.
7. Oblige a second pharmacist to doublecheck all the dangerous medications.
8. Be aware of look-alike or sound-like medications when you are dispensing.

Pediatric patients are especially vulnerable to any medication errors as a) they cannot clearly communicate any discomfort and b) their physiology is still immature, with the renal and hepatic clearing systems still in their early stages of operation. That is why this nurse felt that she could have harmed the child with that excessive dosage.

There is also a big factor that crosses all the segments and specialties of Health Care. There is widespread tiredness and disillusionment in our files as the persistent micromanagement of payors, the still excessive paperwork despite the widespread use of electronic medical records, the offensive demeaning of professional roles by the encroaching of management and bureaucrats, the need for constant updates, etc., has been sapping our enthusiasm, notwithstanding our strong medical vocations.

One veteran professor in our Medical School warned us, the rookies, as follows:

“Hay que dejar la medicina antes que la medicina te deje.”

(You must leave medicine before it leaves you)

Stay distant. Stay safe. Stay beautiful.

What do you think? Please tell us.

Don’t leave me alone.