Pediatric medication errors in the PACU (Post Anesthesia Care Unit), comment


Thank you for this post… it is a great reminder of the importance of the "5 Rights" of medication administration. Med errors happen more times than we would all like to admit. I have worked in the Neonatal ICU for many years and I will admit I just had a wake-up call. It was an extremely busy day in the unit and I was caring for a set of premature twins with almost identical birth weights, therefore same calculation weights used for dosages. I had a laundry list of meds to give to these patients. After I administered a med and I was tearing the patient label off I realized… the med I just gave was for twin "A" and not "B". It was the Right Medication, the Right Dosage (thankfully being twins of the same size… which does not happen all the time), the Right Route, the Right Time and Right Rationale but not the Right Patient……. the label said "XXXXX, baby-A" and not "XXXXX, baby-B". This was a major wake-up call that thankfully did not cause any harm since both of the patients were to get that exact medication at that exact time but regardless this was a reported Med Error! It really reminded me that no matter how busy you may be….. Take your time when administering medications to your patients… the other tasks can wait!! It can happen to any of us¦ BE CAREFUL!!

Original Post
July 30, 2009
Title: Pediatric medication errors in the PACU (Post Anesthesia Care Unit)

When we, as nurses perform assessments on our patients, in this case, a pediatric patient that will be going for any surgery, we often forget the word beneficence (principal of doing well for our patients) or take it for granted.  We go though the assessment form with the patient and most often the parent assisting, sometimes taking aspects of it as routine or perform a ‘run of the mill assessment’. 

The patient, now has his or her surgery and moves through to the PACU.  We always believe that we will always act in the best interest of our patient, the principal of ‘doing good’.  We always plan on never doing harm to our patients- to do no harm-provide the principal of nonmaleficence. 

‘Medication errors involving pediatric patients in the PACU, may occur as frequently as one in 20 medication orders and more likely to cause harm when compared to medication errors overall.’(AORN 2007, vol 85 page 731)  There have been many instances of late with pediatric medication errors, but the one that is foremost in everyone’s mind is the much published case of the newborn twins of actor Dennis Quaid. A medication(heparin) was administered and the dosage was incorrect.   We as nurses have long been educated and re-educated on the ‘5 rights’ of medication administration.  If we would just take the time to check and re-check the medications, there perhaps would be a decreased number of errors.  Pediatric medication dosages are based on the child’s age, weight and condition. A higher percentage of errors were found of pediatric patients where calculations involving decimals, dosage forms and math related as we have to calculate the proper dosage. Hospitals, pharmacists and nurses are continually trialing and attempting to establish standardized policies, procedures and educating our nurses in the proper handling of our pediatric populations, so errors don’t occur.  Do I think we have the problem solved…no.  But we are well aware of this problem and we have begun the journey to rectify the problems.   I certainly do not want any of our pediatric patients to become statistics and our nurses go through the immense pain and suffering if a negative outcome happens. There are many regulatory bodies that could  get involved.  Not to mention, the family and their worries and concerns for their child, and yes, the lawsuit that may prevail. We must all be very cognizant of not only our pediatric patients, but all our patients.  

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