Bad dose of heart meds too often in children

Infants and young children with a heart drug that the wrong dose or at the end of the wrong end of the error more often than medication older children, seeking the guidance of the Johns Hopkins Children's Center published July 6th in pediatrics.

While the researchers found the greatest number of errors in infants aged 1, they say children of all ages are susceptible to such errors, because the providers of access to health manually doses mal weight sensitive and can not properly adulthood of drugs used off label for children.

"We found that errors, heart medicines in children, and it can happen at each step of the way, the requirement for medicines, but the dosage and administration of common fatal error" , said investigators conducting Marlene Miller, MD, M.Sc., Vice President for Quality and Patient Safety in Hopkins Children's.

The researchers stress that the vast majority of the analysis of errors in his study - 96% - very mild and does not demonstrate that harm to patients or patients who have never met, but at 4% (31 ) cases, there were wrong, although no deaths.

The report and the warnings were a thorough analysis of 821 medication errors, volunteers in a national database error reporting. Like Miller, error at each step of the multiple-step procedure for calculating the dose of the prescription, dispensing and drug, with the main cause of the error error dosing of patients, weight , mathematical miscalculation, errors of markets, or more doses of absence taken. In one case the patient weight in pounds sterling has been taken for the weight in kilograms, a gross in the event of an overdose of three drugs for the heart, patients in cardiac arrest.

Half of the error in children younger than 1 year and 90%, children under the age of 6 months. Newborns and young children with congenital heart disease - the four babies to U.S. 1000 - a high risk for this type of error as the heart medications are most often for them, say the researchers. The other half of the dose in patients with error at the age of 1 year and 6 years.

Investigators say some medicines in children of error may be reduced or computer with a command of drug in the double and triple control mechanisms, the probability of faulty or misinterpreted, a little Hopkins Children's already done. In 2006, Hopkins, the researchers show that the order on the Web are less likely to order and a child a dose incorrectly. Given that markets computer may prevent certain types of errors, it is important to find new ways and developing new systems, other types of errors, although, as the dispensing and administration error, while at the same time recognizing the human factor.

"While it is important to check, amend or Fail-Safe system, because the human factor in patient care, we also emphasize the vigilance of staff in case of hospitalization in all aspects of the administration of drugs, distribution of weight of evaluating drugs, "said lead investigators Diana Alexander, MD, of the study, while Hopkins and is now at St. Luke's Regional Medical Center in Boise, Idaho.

The most harmful errors, diuretics, treatment of heart failure and hypotension, in releasing the body of water, and antihypertensive (blood pressure reducing) drug, both now in children with congenital heart disease and increasingly in older children and young people with high blood pressure.