Emergency-medicine residents often miscalculate IV doses for kids

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By Will Boggs MD

NEW YORK (Reuters Health) - Emergency-medicine residents often miscalculate doses for a variety of intravenous medications used to treat children, according to new findings.

Under- or over-dosing of pediatric medication can have devastating consequences, but there are few data on the frequency of resident dosing errors in pediatric-care settings.

Dr. William Bonadio from Mount Sinai St. Luke's Medical Center in New York City reviewed 500 consecutive IV orders for a broad range of medications placed by emergency-medicine residents in the pediatric emergency-medicine department in 2018.

One in five orders (105, or 21%) had calculations that deviated from recommended dosing by more than 10%, he reports in the American Journal of Emergency Medicine, online March 20.

Dr. Bonadio suggests several measures for decreasing dosing calculation errors and ensuring dosing accuracy: having a pharmacist double check all IV-medication orders prior to administration; incorporating a protective feedback system in the electronic health record to alert providers when ordered medication dosing deviates from recommendations; and having the nurse and attending physician confirm the accuracy in resident-ordered IV medication prior to administration.

"Pediatric emergency departments with emergency medicine resident training programs should be particularly cognizant of the potential for medication dosing errors, and promote oversight measures to decrease risk for miscalculation," he concludes.

Dr. Linda H. Barstow, an emergency-medicine clinical pharmacist at Vanderbilt University Medical Center in Nashville, Tennessee, recently assessed dosing errors in emergency-department (ED) antibiotic discharge prescriptions for pediatric patients. She told Reuters Health by email, "This article did not categorize the magnitude of dosing errors or frequency within high-risk medications versus medications with a wide therapeutic window, so it is difficult to estimate the impact on outcomes. It also did not speak to how many of these errors actually reached the patient. From my own research, a 10% deviation can result from rounding to the nearest tablet size or a misinterpretation of diagnosis in chart review, and, for some medications is inconsequential. More information is needed."

"Residents are expected to make calculation errors, as they are unfamiliar with dosing at the beginning of their training," she said. "This report points out not only the importance of dosing education, but presents opportunities from a systems perspective. Safeguards within the electronic medical record need to be implemented."

"The article notes that one area for improvement would be that a pharmacist should double-check all IV-medication orders prior to administration," Dr. Barstow said. "This should be standard of practice in all emergency departments, particularly with high-risk mediations such as insulin, potassium, etomidate, and many others listed on this report."

Dr. Bonadio did not respond to a request for comments.

SOURCE: https://bit.ly/2HXpBbm

Am J Emerg Med 2019.

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