Case Presentation:
A 3‐week‐old was admitted to the pediatrics service for evaluation of fever and administration of parenteral antibiotics. Acetaminophen 15 mg/kg/dose every 4 hours was ordered. The infant received 6 daily doses of acetaminophen equivalent to 90 mg/kg/day for 72 hours. On hospital day 5, the patient's AST and ALT peaked at 1099 and 253, respectively. INR was 1.5, and albumin was within normal limits. Acetaminophen was discontinued. No other etiologies for elevated LFTs were apparent. Maternal hepatitis B status was negative. EBV and CMV titers were unremarkable. Abdominal ultrasound revealed patent hepatic and portal veins. Although the infant's highest acetaminophen level was 8, W‐acetylcysteine was administered as an antidote for potential toxicity. The infant was discharged on hospital day 7 in good condition, with an AST and ALT of 416 and 139, respectively, and an INR of 1.3. Discharge diagnoses were fever and hepatitis.
Discussion:
A systematic literature review of medication errors in children found that although most research to date has focused on the prescribing step, 5%‐27% of medication orders in children contain an error somewhere along the spectrum of the entire delivery process involving prescribing, dispensing, and administering medications. In this case, the physician prescribed acetaminophen without a qualification of the maximum number of doses or amount per day allowed. Because acetaminophen was directly available to the nursing staff, there was no method by which the pharmacy could account for the actual number of doses supplied within a 24‐hour period in a running fashion. It should be noted that the provision to “not exceed 5 doses or 4 grams in 24 hours” was crossed out on the medication administration record by nursing so as to comply with the physician order. There are several strategies that have been studied to decrease medication errors. First, computer physician order entry systems contain decision support systems, such as patient allergy alerts or suggestions for drug doses and frequencies. Less expensive strategies, such as improving physician habits, can also reduce error. For example, patient weights and allergies should be included on each medication order. Vague instructions such as “take as directed” and abbreviations should be avoided. Including pharmacists during rounds can enhance team communication. Electronic medication administration records and automated drug dispensing systems such as Pyxis can also reduce missed doses by removing the pharmacy‐dispensing step completely from the drug‐ordering pathway.
Conclusions:
Although the infant in this case did not suffer severe or permanent morbidity, she had a prolonged hospitalization and administration of a potentially dangerous drug. The systems approach views every medical error as a system failure. It shifts focus from the actions of individuals to the system in which individuals work. The prevention strategies detailed above have been shown to reduce medication errors in children.
Author Disclosure:
J. Tan, none; L. Feldman, none.