Pediatric Informatics: Computer Applications in Child Health (Health ...

354 S.H. Mitchell et al.
work rounds). 14,15 As much of medication management and checking/dispensing is
invisible to the rest of the clinical staff, this expertise provides an additional layer
of error catching and safety in medication ordering. In a recent study, 16 pediatric
clinical pharmacists were effective in intercepting prescribing errors, but did not
capture potentially harmful medication administration errors.
In addition to the presence of trained pediatric pharmacists, the role of PharmIS
in error catching as part of an integrated medication delivery system that includes
connection to CPOE and electronic medication administration records is central.
The continuing evolution of PharmIS and PharmIS CDS as well as participation
of clinical pharmacists in development of CPOE, eMAR, and other tools within
the medication delivery cycle will be important in reducing errors and improving
quality of the pediatric medication use system.
27.6 Case Study: Elimination of the “Rule of Six”
in Pediatric Continuous Infusions 17
At a 180 bed tertiary pediatric academic center, a redesign project to reduce continuous
infusion medication errors and to transition safely to Joint Commission
mandated standardized infusion concentrations (SC) 13 was undertaken. After an initial
assessment of baseline infusion order error rates, a Web-based calculator 18 was
developed in 2003 to reduce errors, using the “Rule of Six” resulting in a significant
and sustainable decrease in prescribing errors. The Joint Commission requirement
for transition of all infusions to standard concentrations 19 led to: (a) specification of
standard concentrations for 51 infusion drugs, (b) redesign of the infusion calculator
with an interface to the hospital census and additional decision support to facilitate
use of SC, (c) construction of pre-built choices into the associated PharmIS for SC
(thus eliminating pharmacist calculations) and (d) incorporation of syringe “smart”
pumps for infusions. This facilitated transition to standard concentrations for infusions
with a further reduction in error rates.
The success of the system and its subsequent incorporation into a commercial
CPOE system was the result of its multidisciplinary approach which included the
expertise of pediatric clinical pharmacists. This expertise, which included knowledge
about medication stability, usual and extreme doses, appropriate flow/infusion rates,
concentration limits (in peripheral vs. central infusions), and commercially available
dosage forms was essential for developing drug-specific SCs for pediatric infusions.
References
1. Rich, Darryl S. New JCAHO medication management standards for 2004. Am J Health-Syst
Pharm. 2004;61:1349–1359.
2. Chaffee BW, Bonasso J. Strategies for pharmacy integration and pharmacy information
system interfaces, Part 1: history and pharmacy integration options. Am J Health Syst Pharm.
2004;61(5):502–506.