Small Patients, Big Consequences in Medical Errors

WHEN 6-year-old Chance Pendleton came out of surgery for a wandering eye, it was obvious that something was not right. “He was crying hysterically, vomiting and kept saying, ‘I wish I was dead,’ ” his mother, Grace Alexander, of Paris, Tex., recalled.

The boy had been through surgery before and had never reacted this way. “The nurse was quite peeved and wanted me to calm him before he disturbed anyone,” said Ms. Alexander, who said Chance was denied more pain and anti-nausea medication. “She thought he was just throwing a tantrum.”
After about 20 minutes, another nurse walked by, and Ms. Alexander beckoned her for help. The nurse checked the intravenous line in Chance’s ankle and saw that it wasn’t inserted correctly. He wasn’t receiving any medication. She immediately fixed it, bringing relief to Chance in a matter of seconds.
Medical mistakes, though also common in adults, can have more serious consequences in children, doctors say. The actor Dennis Quaid’s newborn twins nearly died last year after receiving 1,000 times the prescribed dose of a blood thinner. Other infants have died from the same error. A study in the journal Pediatrics in April found that problems due to medications occurred in 11 percent of children who were in the hospital, and that 22 percent of them were preventable.
An Institute of Medicine report nearly a decade ago highlighted the prevalence of medical errors, and they are still a major problem. “There’s been slow progress in the decline of these errors,” said Dr. Peter B. Angood, chief patient safety officer of the Joint Commission, the independent hospital accreditation agency. The agency recently called onhospitals to further reduce medication errors in children.
Children are also the victims of diagnostic errors, incorrect procedures or tests, infections and injuries.
Medical errors pose a greater threat to children than to adults for a number of reasons. They are physically small, and their kidneys, liver and immune system are still developing. Even a tiny increase in the dose of medication can have serious effects — especially in babies born prematurely. And if children take a turn for the worse, they can deteriorate more rapidly than adults. Children also are less able to communicate what they are feeling, making it difficult to diagnose their problem or know when a symptom or complication develops.
Adult medications are prepackaged and have standardized doses, but pediatric medications vary, based on the child’s weight and sometimes height, requiring doctors to make calculations. It is easy to misplace a decimal point, a tenfold error.
Typically, an adult formulation is diluted for children, and sometimes “the amount of medication being diluted is smaller than an air bubble in a syringe,” said Dr. Rainu Kaushal, director of quality and patient safety at the Komansky Center for Children’s Health at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
“A pharmacist can get orders for 55 milligrams, 65 milligrams, 70 milligrams of the same medication,” said Michael R. Cohen, president of the Institute for Safe Medication Practices, a nonprofit health care education organization. And medications for children come in different formulations, from drops to liquids to chewables. These variables increase the chance of human error, Dr. Kaushal said.
The Joint Commission reported that about 32 percent of medication errors in children in the operating room involved the wrong dose, compared with 14 percent in adults.
But not all errors happen in hospitals. Karen Rhodes was giving her 2-year-old daughter, Lanie, the prescription medication Zyrtec for allergies three times a day, as the label indicated. But Lanie began to suffer tremors, her breathing grew shallow, and she became “zoned out,” her mother said. It turned out she was getting three times the recommended dose; the drug should have been taken once a day. It was the pharmacist’s error, said Mrs. Rhodes, of Spartanburg, S.C.
At the American Academy of Pediatrics annual meeting in 2006, Dr. Kaushal reported that potentially harmful medication errors affected 26 percent of children in outpatient care.
“There needs to be more medications specifically manufactured for the pediatric population, more standardized dosing regimens and very accurate and clear labeling and packaging of medications,” said Dr. Angood of the Joint Commission. A labeling issue caused the mix-up that led to the overdose of the Quaid twins. The label for a 10-unit dose of the blood thinner heparin, which is used to flush intravenous lines, looked similar to the label of the 10,000-unit dose that the twins were given.
TECHNOLOGY has helped to reduce medication errors. Two methods are favored by experts: an electronic prescribing system known as computerized physician order entry, and a system in which a bar code assigned to a patient is swiped against the bar code of the drug he is about to receive.
But these technologies are expensive and require training. Only about 10 percent of hospitals in the United States use computerized prescribing, and 20 percent use bar coding, said Dr. Cohen. One technology, adopted by about half of the hospitals in the United States, is the smart pump, a programmable intravenous device that regulates the amount and timing of drug delivery. Infections, which are considered errors because they are preventable, are also common among children being treated in hospitals. Studies of neonatal and pediatric intensive care units found that infections topped the list of medical errors, followed by medication errors and injuries from catheters (many are left in too long), said Dr. Paul J. Sharek, chief clinical patient safety officer of the Lucile Packard Children’s Hospital at Stanford in Palo Alto, Calif.
Misdiagnosis is also common and can lead to serious complications or death. A study of malpractice lawsuits involving children visiting emergency departments found thatmeningitis, appendicitis and broken arms were the most common misdiagnosed conditions.
Hospitals can take simple measures to reduce mistakes. For example, when members of a surgical team take a time-out a moment before operating to check that they have the right patient, the right procedure and the correct location, errors are reduced.
Parents need to be the eyes, ears and advocates for their children. “Parents have to pay attention and speak up,” said Dr. Steve Selbst, professor of pediatrics at Jefferson Medical College in Philadelphia, who conducted the study on malpractice suits. “You know your child, and if you feel something’s wrong, go up the chain of command.”
Chance Pendleton’s mother said she was not aggressive enough. “I wish I had been more confrontational sooner,” she said. “That was the worst 20 minutes of my life.”
Here are some tips from experts for parents to lower the chance their child will be harmed by his or her treatment.
ID BRACELETS If your child is in the hospital, make sure the identification bracelet is worn at all times.
HYGIENE Ask all health care providers to wash their hands before approaching your child.
INFORMATION Before a procedure, ask the surgery team’s members if they know exactly what the procedure is.
KNOWLEDGE Schedule a time every day to review with the physician and nurses the medications your child is taking and any other information about his care.
AWARENESS Keep an eye on catheters and incisions, looking for redness and swelling.
ASK QUESTIONS If your child is very sick, make sure a pediatric specialist is involved, and ask whether your child should be moved to a children’s hospital.
TALK ABOUT IT Express your concerns about a missed diagnosis.
BE PREPARED Carry a list of the medications your child is taking and remind doctors about any allergies your child has.
DOUBLE-CHECK Understand why medications are being ordered, and don’t be afraid to ask the doctor to double-check that he used your child’s correct weight and height in calculating the dose.
MEDICINES Familiarize yourself with the medications so that you can recognize if your child is given the wrong pill or liquid. Ask about potential complications and whom to contact if your child has a reaction.
VIGILANCE Be especially watchful if your child is taking multiple medications or is on high-risk medications like chemotherapy drugs, insulin or heparin, or if your child has a compromised immune or organ function.
THANKS  http://www.nytimes.com/2008/09/15/health