Avoiding Pediatric Drug Errors

Pediatric drug errors are unfortunately common. The literature states that medication errors occur in 5% to 27% of all pediatric medication orders, a very sobering number. Considering that many of these errors occur in the smallest, and therefore most vulnerable, of our little patients, the potential impact is especially great.

For the last 3 months, I’ve been teaching critical event training classes for our OR and Perioperative RNs, Anesthesia MDs and CRNAs, and OR techs in preparation for opening our new hospital in San Diego. Several of the scenarios involved pediatric cases. As part of that process, I’ve been reviewing with my providers ways to avoid the potentially deadly problem of pediatric drug dosing errors as well as ways to avoid them. Let’s discuss some of the ways to make pediatric medication administration safer.

Know the Correct Pediatric Dose

Avoiding pediatric drug errors starts with knowing the correct dose. If you’re not used to treating pediatric patients, you may not know the dose per kg of the medications you use. If you’re not sure, look it up. Before using an unfamiliar drug for any patient, especially a pediatric patient,  look it up in the Physician’s Desk Reference (PDR), do a google search, call the pharmacy, or even ask a colleague. There are also multiple excellent pediatric dose calculator apps available for your smart phone devices. Be sure to be safe.

Units Count

Verbal orders are common when treating emergencies, when the time to write down an order does not exist. However, it’s unfortunately common to give verbal orders without  using units of dosage. If I’m in a code situation, and I tell my RN to “give one”, I am forcing my nurse to guess “one what”. Do I mean one ml, one mg, one gram, one liter? Sure, my nurse could guess correctly, but why chance it.

It’s especially important to make the distinction between mg and ml because making that mistake often changes the patient’s dose significantly.

Broselow Tape

Many of you have experience with the Broselow System, which was invented to fill the need of treating critically ill children when their age and weight is not known. The system consists of a color coded cart and a Browlow measuring tape. The tape uses the child’s height (or length if treating a baby) to provide instructions regarding dosage of critical medications, the size of emergency equipment such as oral airways, endotracheal tubes and laryngoscope blades, and the level of shock voltage to use during a cardioversion or defibrillation.

You use the tape by measuring the length of the child from top of the head to the feet. The color band where the feet lie directs the user to a color-coded drawer with size appropriate equipment for that length child. The Broselow system is designed for children less than about 12 years old or about 36 kg.

The Broselow system is easy to use, however, the tape gives the dosage of medications for each size child in mg. The problem is that we administer liquid medications in ml. Changing from ml to mg requires math, and whenever math is involved, errors follow.

Check Your Math With Someone Else

Many of my younger SRNAs and residents struggle to do simple mental math because, to be honest, today’s society does not force them to practice. They live in a world of smart phones with calculators. Unfortunately, it’s easy to enter a wrong number or fail to type the decimal point in the right spot on a calculator. Doing a mental math  pre-calculation alerts you if the number the calculator spits out looks bigger or smaller than expected.

In addition, during an emergency, everyone’s ability to do math is hampered.

To avoid pediatric drug error, always check your math. Don’t be afraid to write down the calculation and by all means do check it on a calculator. It’s especially important to have someone else check your math for critical doses, especially of medications you rarely or never administer and especially if they are tiny. Having someone check your math is a sign of wisdom, not weakness.

Pediatric Dose Calculators

There are quite a few free or inexpensive pediatric dose calculation apps available for the computer and for your smart device or phone. View these as cognitive aides, not crutches.

My hospital subscribes to a service providing the on-line eDose app. With this app we print out a list of emergency drugs (with doses in both mg and ml) specific to each child’s weight, for every child.

One safety tip for using drug calculators and eDose: make sure the concentration of the drug you are using is the same one the app is using. The last few years many hospitals, my hospital included, has faced the occasional drug shortage as manufacturers have temporarily stopped production of certain medications. Sometimes the replacement drug is not the same concentration, which could lead to over or under dosing. Always check your concentration before drawing up your medications.

Draw Up the Correct Dose

Once you know the dose, and the ml, you must now draw up the medication. Accurately and safely injecting 0.15 ml of epinephrine intravenously from a 10 ml bristojet of cardiac epinephrine is not physically possible.

I recently learned a terrific way of drawing up small doses of medications using a 1 ml syringe and a stopcock. Simply attach your 5 or 10 prefilled drug syringe to one port of the stopcock and fill the dead space of the stopcock with drug. Next attach your one ml syringe to the other port. Turn the stop cock so that the two syringes can inject into each other. Now you can easily and quickly accurately transfer your medication in very tiny amounts to the one ml syringe. If you overshoot you can squirt the excess back into the bigger syringe.

Photo of first step in technique to easily transfer medications from syringe to serge for very small doses.

First attach your original 5 to 10 ml drug syringe to a stopcock and prime the stopcock. Here, we’re using a saline filled syringe as an example. You can see the fluid at the port in this photo. If you eliminate the air at the start, you won’t need to deal with removing air bubbles from your 1 ml syringe.

Photo of second step in technique to easily transfer medications from syringe to serge for very small doses.

Next attach your 1 ml syringe. You may now easily inject medication from one to the other, precisely drawing up very small doses quickly and easily.

There are two important safety tips for using this method:

  • Never put this stopcock in the patient’s IV line. This method is a transfer you do at the back table and then hand the one ml syringe to the provider injecting the drug. There is simply too much risk of having the stopcock turned the wrong way and accidentally injecting way more drug than you intended.
  • Always use a fresh stopcock to draw up a different medication. Never use the same stopcock. When dealing with dosages of 0.1 ml, there is more than that amount of drug in a stopcock, making injection of an unintended drug highly likely.


Of course, another way to administer small dosages of medications is to dilute the drug into a larger volume. If you dilute make sure your math is correct – have someone check it! Label the syringe.

Label Your Syringe

Always label the syringe, with both the drug AND the concentration. The only exception to this rule is when you will immediately inject the contents. If you will put the syringe down, then label it.

I have seen providers count on others knowing the concentration based on whether they diluted into a 5 or a 10 ml syringe. Sure, your compatriot could guess what you intended correctly. But they could also guess wrong. Be safe, label accurately.

When labeling, and when writing orders, always use leading zeroes before the decimal point. An example of a leading zero is: 0.5 mg/ml. A leading zero alerts the reader that we are dealing with a very low dose and concentration.

Never use following zeroes. An example of a following zero is: 10.0 mg. It is too easy to misread this as 100 mg, which is 10X the dose.

Read the Vial and the Syringe Label

I’ve said this before in a previous post but I’ll say it again. Always read the vial both before you draw up the medication as well as after you have finished drawing up the medication. Sometimes we see what we want to see when we first pick up a vial. Double check.

When injecting from a syringe, read the syringe label before inserting it into the line. Read the label again before pushing the plunger.

Know Which Drugs Carry Risk for Children

One good example is codeine. Although the initial FDA warnings about potentially fatal overdose from codeine in children were released in 2012, I’m recently discovered that a few of my surgeon and nursing colleagues were still unaware of the potential risks. Cytochrome P450 2D6 is a liver enzyme that transforms many drugs, including the conversion of codeine to the active analgesic morphine. There are multiple enzyme variants of P450. The 2D6 variant is more rapid and results in more complete conversion, and therefore results in a much higher-than-normal blood level of morphine. High levels of morphine may result in respiratory depression, which can be fatal. For for information on codeine click here.

Good Communication Is Key

During a crisis, there is a lot of noise, activity, people coming and going, and often confusion.

A good practice is to repeat the verbal order or information you just heard. Repeating the order does two things.  If my nurse reads  the order back to me during a code, including the units, I know he or she heard the order, and I also know that he or she heard it correctly. In the chaos of the moment it’s very easy for orders to simply not be heard, or to be heard wrong.

I saw this during our mock emergencies. The doctor in one scenario needed to calculate a dose for our simulator baby.  Not knowing the concentration of the medication in the vial, she asked. The nurse holding the vial told the nurse next to her, but closer to the doctor, that it was 50 mg/ml. That second nurse heard 15 mg/ml, didn’t read it back and told the doctor 15mg/kg. The resulting dosage based on that concentration was wrong. Fortunately this was a simulation and no harm resulted. But how easy it would have been to avoid that mistake if nurse two had simply repeated what she heard to nurse one. The error would have been caught before it happened.

Encourage Your Helpers To Speak Up

Make sure your helpers know that they should question you if they have a concern about anything that you are about to do. This is especially true if you know you are compromised. We all have days when we have been distracted by a death or serious illness in the family, or when our teenager has wrecked the car, or when we simply have not had enough sleep the night before. Your team can watch your (and your patient’s) back on those hopefully rare occasions.

And when your team gives you feedback or questions you, accept their comments gracefully. If there is no problem thank them for verifying and explain why you are doing what you’re doing. Trust me.  Someday your team member will point out something to you that you really do want to know and it will help prevent potential disaster.

We are all capable of medication error. But we all have the power to avoid pediatric drug errors, as well as all drug errors. Make health care safer for our patients.

May the Force Be With You
Christine Whitten MD, author Anyone Can Intubate, 5th Edition
Pediatric Airway Management: A Step-By Step Guide

Suggested Reading

  1. Michael L. Rinke, MD, PhD,a David G. Bundy, MD, MPH,b Christina A. Velasquez, MD,c Sandesh Rao, MD,d Yasmin Zerhouni, MD,e Katie Lobner, MLIS,f Jaime F. Blanck, MLIS, MPA,f and Marlene R. Miller, MD, MScg. Interventions to Reduce Pediatric Medication Errors: A Systematic Review
  2. Cimino MA, Kirschbaum MS, Brodsky L, Shaha SH; Child Health Accountability Initiative. Assessing medication prescribing errors in pediatric intensive care units. Pediatr Crit Care Med. 2004;5(2):124–132
  3. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285(16):2114–2120
  4. Marino BL, Reinhardt K, Eichelberger WJ, Steingard R. Prevalence of errors in a pediatric hospital medication system: implications for error proofing. Outcomes Manag Nurs Pract. 2000;4(3):129–135
  5. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999
  6. http://pediatrics.aappublications.org/content/pediatrics/134/2/338.full.pdf
  7. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. Medication Errors and Adverse Drug Events in Pediatric Inpatients. JAMA. 2001;285(16):2114-2120. doi:10.1001/jama.285.16.2114

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten     Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

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2 thoughts on “Avoiding Pediatric Drug Errors”

  1. Thank you very much for the great post. I just write a blogpost about peds in EMS for a German FOAM blog and would like to ask whether I get permission to use the syringe/stopcock pic for this. Thanks in advance

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