As a pharmacy error attorney, I have witnessed first hand many cases where children and adults are given the wrong medication due to medications have similar names and sizes so they are easily confused by pharmacy staff. In addition, children taken to adult hospitals suffer injuries or fatalities because these hospitals carry mostly adult size doses of medication so when a child is treated, their medication is often confused with the appropriate adult size.
According to an article from the American Medical News, a shocking 11% of child patients have adverse drug events during hospital stays. Most of the results came from children staying in adult hospitals and given adult sized doses instead of the pediatric size. Dr. Sharek, chief clinical patient safety officer at Lucile Packard Children’s Hospital in Palo Alto, Calif. said “We are so used to writing pediatric, weight-based doses and when children are being cared for at adult hospitals staffed by adult-based nurses and adult-based pharmacists, that’s a type of error that could theoretically occur a lot more frequently.” The American Medical News goes on to say “The Joint Commission, which accredits and certifies more than 15,000 U.S. health care organizations and programs, said in its sentinel event alert that children are at greater risk for adverse drug events. That’s because most medications are formulated and packaged for adults, and most hospitals and emergency departments are geared toward caring for adults.” The Joint Commission is further investigating these problems and suggests that hospitals identify and administer pediatric medications. Frank Federico, RPh, said “Medication should be delivered to the nursing unit or available in ready-to-administer fashion. That way, there is less that nurses have to do and less chance for error.”