Pediatric Dose Calculation Issues and the Need for Human Factors–Informed Preventative Technology Optimizations

Abstract

Background: Dose calculation errors are one of the most common types of medication errors impacting children and they can result in significant harm. Technology-based solutions, such as computerized provider order entry, can effectively reduce dose calculation issues; however, these technologies are not always optimized, resulting in potential benefits not being fully realized. Methods: We analyzed pediatric dose-related patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System using a task-analytic approach that focused on information being used in the dose calculation, calculation errors during ordering, and errors during dose preparation or administration. From these reports, we identified whether the patient was impacted by the error, the type of medication involved, and whether a technology optimization could have mitigated the issue. Results: Of the 356 reports reviewed, 326 (91.6%) met the criteria for a dose calculation issue. The 326 reports meeting criteria had the following dose calculation issue types: wrong information used in the calculation (49 of 326, 15.0%), incorrect calculation during ordering (97 of 326, 29.8%), and calculated dose was not properly used or incorrect calculation during preparation/administration (180 of 326, 55.2%). Most of these dose calculation issues impacted the patient (219 of 326, 67.2%). Analysis of these issues by patient age group and drug class also revealed interesting patterns. Technology optimizations potentially could have addressed 81.6% of the dose calculation issues identified. Conclusion: While many healthcare facilities have adopted health information technology and other devices to support the medication process, these technologies are not always optimized to address dose calculation issues. Human factors–informed recommendations, a safety checklist, and test cases for optimizing technology are provided in the context of these findings.

Impact of a clinical decision support system on paediatric drug dose prescribing: a randomised within-subject simulation trial

“…29 30 Last but not least, we think that it is undisputable that we should prevent the occurrence of an error in the first place by using a dose calculator rather than to rely on post hoc measures or on the commendable vigilance of the HCPs. 10 11 28 …”

“…Interestingly, clinical information system providers do not need to conduct usability tests as compared with European medical device manufacturers 29 30. Last but not least, we think that it is undisputable that we should prevent the occurrence of an error in the first place by using a dose calculator rather than to rely on post hoc measures or on the commendable vigilance of the HCPs 10 11 28…”

“… 6–9 Especially in clinical settings, where resources are often limited and timing of a treatment can be critical, the likelihood of human errors is even greater. 10 11 Consequently, there is a need to prevent dosing errors by supporting the physicians that prescribe the dosage as well as the clinical pharmacists that validate the prescriptions. Clinical decision support systems (CDSS) are thus regarded as a promising strategy to address the unique needs of paediatric pharmacotherapy.…”

“…When considering both, the effort to search for appropriate dosing information and the need to manually calculate individual dosages, it is not surprising that dosing errors are a main cause of preventable harm in paediatric pharmacotherapy 6–9. Especially in clinical settings, where resources are often limited and timing of a treatment can be critical, the likelihood of human errors is even greater 10 11. Consequently, there is a need to prevent dosing errors by supporting the physicians that prescribe the dosage as well as the clinical pharmacists that validate the prescriptions.…”

Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system

“…Indeed, Tolley et al identified the lack of dosing support as the most crucial factor that contributed to CPOE-related errors in paediatrics 10. Previous studies in paediatric settings have also highlighted the importance of minimising disruptive alerts and modifying directly the ordering workflow to avoid error-prone steps (eg, implementing rules to avoid 10-fold errors directly in the CPOE) 11 12. Therefore, designing and implementing an effective and satisfactory system tailored to the paediatric population’s needs and local clinical environment is critical to ensuring medication safety 13–16…”