Patient Safety Tip of the Week

January 31, 2017    More Issues in Pediatric Safety



In our January 17, 2017 Patient Safety Tip of the Week “Pediatric MRI Safety” we noted that many safety issues for children undergoing MRI result from the confluence of vulnerable patients being temporarily in an environment where communication and coordination issues can be problematic. But communication issues can affect the safety of pediatric patients in almost any venue. Young children obviously must rely on parents, other adults, and other caregivers for overseeing their safety. Moreover, they may be unable to convey their own feelings or symptoms, at least in a verbal fashion. Children are also vulnerable to errors because doses of their medications and IV fluids may require calculations based upon weight and such calculations may be subject to errors.


But the behavior of parents can also affect the care their children receive. In our September 22, 2015 Patient Safety Tip of the Week “The Cost of Being Rude” we discussed a study (Riskin 2015) showing shown how rudeness among the healthcare team can negatively impact performance. Now the same researchers have demonstrated in simulation exercises that rudeness by parents may also negatively impact performance by healthcare workers (Riskin 2017).


They randomly assigned NICU teams to either an exposure to rudeness (in which the comments of the patient’s mother included rude statements completely unrelated to the teams’ performance) or control (neutral comments) condition. Rudeness had adverse consequences not only on diagnostic and intervention parameters but also on team processes, such as information and workload sharing, helping and communication, central to patient care.


There’s little question that even such subtle behaviors can introduce biases that may foster diagnostic errors. There has recently also been attention in the adult patient safety literature to the occurrence of diagnostic errors in patients who exhibit disruptive behaviors (Mamede 2017, Redelmeier 2017).


Communication issues were also a key finding in a recent analysis of primary care patient safety incidents involving sick children from England and Wales’ National Reporting and Learning System between 2005 and 2013 (Rees 2017). Of the 2,191 safety incidents, 30% were harmful, including 12 deaths and 41 cases of severe harm. The researchers identified several priority areas for improvement:


We don’t know enough about the UK telephone triage system(s) to know whether such systems in the US may be vulnerable to the same issues. In such systems, the person receiving the phone call from a parent concerned about their child lets the parent describe the problem, then selects a computerized protocol that prompts them to ask further questions, after which they provide advice. In the Rees study two common issues were: (1) choosing the wrong protocol (for example, choosing the “head wound” rather than the “head trauma” protocol) and (2) failure to use “critical thinking”. We wonder if some of the latter was really a matter of the telephone advisors simply not having adequate training in some areas. For example, one incident described a feverish 4-month old who had asymmetric pupils and a hard fontanelle. The health advisor commented that he did not know the implications of a hard fontanelle and followed a simple “generally unwell” protocol and incorrectly answered that the infant was able to respond normally despite the mother’s comment that the infant was “dazed” and “drowsy, not with it”.


As you might expect, medication-related incidents were most common and over half were related to dispensing errors in community pharmacies. Anticonvulsants, antibiotics, and asthma medications were implicated most often. Wrong dosage, wrong medication, and incorrect labeling were specifically mentioned. Communication errors with the parent contributed frequently to medication errors, especially when the parents were administering the medication at home.


We’ve previously described how parental health literacy, numeracy in particular, can render children vulnerable to medication errors (see our What’s New in the Patient Safety World columns for June 2012 “Parents' Math Ability Matters” and November 2014 “Out-of-Hospital Pediatric Medication Errors” and our January 13, 2015 Patient Safety Tip of the Week “More on Numeracy”).


Dosing errors related to the vehicles used for administration of medications to children have also been problematic. In our What's New in the Patient Safety World columns for April 2015 “Pediatric Dosing Unit Recommendations” and September 2015 “Alert: Use Only Medication Dosing Cups with mL Measurements” we discussed use of metric units for liquid medications administered to pediatric patients (AAP 2015). Use of measures such as “teaspoon” and “tablespoon” should no longer be used. Moreover, the correct abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”). Dispensing devices are also critical. Pharmacies, hospitals, and healthcare centers should distribute appropriate-volume milliliter-based dosing devices such as syringes. And the syringe (or other dosing device) should not be significantly larger than the dose prescribed. And a national alert recommended hospitals replace medication dosage cups that use units other than mL (NAN 2015).


The 2015 AAP statement also recommends that manufacturers avoid labeling, instructions or dosing devices that contain units other than metric units. But poorly designed labels and packaging continue to contribute to errors. A recent study in 3 urban pediatric clinics (Yin 2016) randomly assigned parents to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. 84.4% of parents made 1 or more dosing errors and 21.0% made 1 or more large error. More errors were seen with cups than syringes, especially for smaller doses. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used. The authors recommend that use of oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.


Children are also more vulnerable to 10-fold dosing errors, primarily because dose calculations often result in results with decimal points. The decimal points can be overlooked, resulting in administration of a dose that is 10 times (or 100 times if there are two digits following the decimal point) higher than intended. In our September 2011 “Dose Rounding in Pediatrics” we discussed under which circumstances it might be appropriate to keep a decimal point and when the dose should simply be rounded to eliminate the need for a decimal point.


More information on pediatric medication errors outside the hospital can be found in our November 2014 What's New in the Patient Safety World column “Out-of-Hospital Pediatric Medication Errors” and May 7, 2013 Patient Safety Tip of the Week “Drug Errors in the Home.


We’ve also discussed the problems often seen with opioids in children, particularly those related to use of codeine (see columns listed below). These columns described the original cases of death and serious adverse effects in children treated with codeine following adenotonsillectomy for obstructive sleep apnea. The problem originally noted for codeine was that there are genetic variations that cause some people to be “ultra-rapid metabolizers” of codeine, which leads to higher concentrations of morphine in the blood earlier. But recommendations have now gone further than just avoiding codeine after adenotonsillectomy and it is now recommended that codeine not be used for pain or cough in children. And children are often the victims of accidental ingestion of discarded transdermal patches of fentanyl or other dangerous medications.


Our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” had an extensive section on the adverse outcomes of pediatric patients receiving sedation. Young children are particularly vulnerable because they are often sedated since they may be uncooperative for dental procedures. Moreover, many such incidents have occurred when a child is restrained by a device called a “papoose”. Proper procedures and guidelines for pediatric sedation were discussed in our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation”.


Overdiagnosis, overutilization of testing, and overtreatment may result in harm to children, just as it can in adults. We’ve often discussed the Imaging Gently® and Imaging Wisely® campaigns, which are attempts to reduce the inappropriate use of imaging with ionizing radiation when safer alternatives are available (see, for example, our January 2017 What's New in the Patient Safety World column “Still Too Many CT Scans for Pediatric Appendicitis”). A recent review of articles published in just one year (2015) provides insight into the magnitude of these problems in children (Coon 2017). Their findings included evidence for overdiagnosis of hypoxemia in children with bronchiolitis and skull fractures in children suffering minor head injuries. Findings of overtreatment included evidence that up to 85% of hospitalized children with radiographic pneumonia may not have a bacterial etiology; many children are receiving prolonged intravenous antibiotic therapy for osteomyelitis although oral therapy is equally effective; antidepressant medication for adolescents and nebulized hypertonic saline for bronchiolitis appear to be ineffective; and thresholds for treatment of hyperbilirubinemia may be too low. Regarding overutilization, they suggested that the frequency of head circumference screening could be relaxed; large reductions in abdominal computed tomography testing for appendicitis appear to have been safe and effective; and overreliance on C-reactive protein levels in neonatal early onset sepsis appears to extend hospital length-of-stay.


Pediatric safety issues such as car and bicycle safety, accidental poison ingestions, falls, firearm accidents, and others are beyond the scope of today’s column.


These are but a few of the many possible patient safety issues potentially affecting one of our most vulnerable patient populations. Some are due to the unique biological and physiological characteristics of children but even more may be related to the fact that communication, which is always an error-prone process, usually happens through third parties rather than directly with children.



Some of our other columns on pediatric medication errors:


November 2007          1000-fold Overdoses by Transposing mg for micrograms

December 2007           1000-fold Heparin Overdoses Back in the News Again

September 9, 2008      Less is More and Do You Really Need that Decimal?

July 2009                     NPSA Review of Patient Safety for Children and Young People

June 28, 2011              Long-Acting and Extended-Release Opioid Dangers

September 13, 2011    Do You Use Fentanyl Transdermal Patches Safely?

September 2011          Dose Rounding in Pediatrics

April 17, 2012             10x Dose Errors in Pediatrics

May 2012                    Another Fentanyl Patch Warning from FDA

June 2012                    Parents’ Math Ability Matters

September 2012          FDA Warning on Codeine Use in Children Following Tonsillectomy

May 7, 2013                Drug Errors in the Home

May 2014                    Pediatric Codeine Prescriptions in the ER

November 2014          Out-of-Hospital Pediatric Medication Errors

January 13, 2015         More on Numeracy

April 2015                   Pediatric Dosing Unit Recommendations

September 2015          Alert: Use Only Medication Dosing Cups with mL Measurements

November 2015          FDA Safety Communication on Tramadol in Children



Some of our previous columns on opioid safety issues in children:






Riskin A, Erez A, Foulk TA, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics 2015; 136: 487-495



Riskin A, Erez A, Foulk TA, et al. Rudeness and medical team performance. Pediatrics 2017; doi:10.1542/peds.2016-2305



Mamede S, Van Gog T, Schui SCE, et al. Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment. BMJ Qual Saf 2017; 26: 13-18



Redelmeier DA, Etchells EE. Unwanted patients and unwanted diagnostic errors. BMJ Qual Saf 2017; 26: 1-3



Rees P, Edwards A, Powell C, et al. Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis. PLOS One Medicine 2017; published January 17, 2017



AAP (American Academy of Pediatrics). Committee on Drugs. Policy Statement. Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published online March 30, 2015



NAN (National Alert Network). Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. NAN 2015; June 30, 2015



Yin HS, Parker RM, Sanders LM, et al. Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics 2016; published online early September 12, 2016



Imaging Gently®



Imaging Wisely®



Coon ER, Young PC, Quinonez RA, et al. Update on Pediatric Overuse. Pediatrics 2017; Published Ahead of Print January 3, 2017






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