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Paediatric patients are all sizes and weights, and thus dosing of intravenous medication infusions for children must be patient-specific. Calculations using methods such as the ‘rule of six’ and preparation of individualized medication solutions may be serious sources of preventable medication errors, particularly for ‘high-alert’ drugs in paediatric patients (1,2). This is especially important in critical care when time is of the essence and high-alert drugs are more frequently used (3,4). The Institute for Safe Medication Practices, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) in the United States and the Canadian Council on Health Services Accreditation recommend against the use of unique or variable concentration solutions (1,5,6). As of 2008, the JCAHO will require that hospitals stock and prepare a limited number of standard concentrations (SCs) of intravenous medications (1,5). Traditionally, doses for infusions have been translated into a medication concentration such that the numerical value of the infusion flow rate matches the dose. A common method is the ‘rule of six’ – the dose (μg/kg/min) equals the infusion rate (mL/h) when the concentration of drug (mg/100 mL) is six times the patient weight (kg) (7). However, when using such a system, solution concentrations may exceed the recommended maximum for heavier patients. Also, to meet unit-specific preferences, nurses and physicians, using a variety of possible formulas, may re-do calculations and change medication solutions on transfer. This practice not only wastes time and materials, it poses risks due to the interruption of medication (particularly for cardiac patients on medications such as adrenaline or dopamine) and repeats the risks inherent in providing medication. The traditional variable concentration approach is subject to errors in the calculation of the solution drug concentration, preparation of the individual infusion or the setting of the solution infusion rate (8–10). Using a small number of centrally prepared SCs reduces the potential for error in solution preparation and the risk of contamination from multiple-use medication vials. ‘Smart pumps’ may be used to implement SCs, reducing calculation and rate-setting errors, but this technology is expensive and may not be in place. It was hypothesized that hospital departments caring for critically ill children could make the transition from unit-specific variable concentration drug preparation to SCs without substantial additional infrastructure or funding, in a manner acceptable to frontline users. The present report describes the design and implementation of SCs of selected high-alert medications, with computer support, at a Canadian children’s hospital. The intent was to improve and standardize provision of medications across three main hospital areas – the emergency department (ED), the paediatric intensive care unit (PICU) and the operating room (OR). |
