Paediatric Prescribing Pitfalls

Near misses and Good catches

Nicolette Graham, Antimicrobial Stewardship Pharmacist,
Lady Cilento Children’s Hospital
Objectives of this session
• To understand the importance of safe prescribing
• Medication safety – why are children vulnerable?
– Understand how children are different to adults in terms of
the use of medications
• Cases– Near misses and Good catches
• Paediatric resources to support safe prescribing
Polleverywhere

• Join the Poll:

– Log in via your smart device by typing the following
into your search engin/URL:
PollEv.com/nicolettegra067
….and then your response…

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Question 1:

At which point of the healthcare journey, is a

medication error most likely to occur?
A. Primary care
B. Emergency department
C. As an inpatient in hospital
D. At home, after hospital admission
E. All of the above

Submit your response: PollEv.com/nicolettegra067

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 Incidence of Adverse Medicines Events (AME)
at Transition of Care
Primary Care
• More than 50% of medication 10% of patients seen in general practice
errors occur at transitions of care experienced AME in preceding 6 months (1)
4.6% resulting in hospitalisation
– Admission, transfer and
discharge
• 20% of adverse medicine events
Post Discharge
result from errors at interfaces •12 – 15% patients have an error on Admission to Hospital
of care discharge script (5,6) 30 – 70% of patients ≥ 1 unintended
•2-4% readmissions to hospital variation between medication history and
medication related (7) admission orders (2,3)
• Readmission 2.3 times more
likely if ≥ 1 medicines
unintentionally omitted from the
discharge summary
During Hospital stay
Paediatrics: 7 in 100 ADEs resulted in harm
(4)

1. Miller GC, Britt HC, Valenti L. Adverse drug events in general practice patients in Australia. Medical Journal of Australia 2006;184(7):321
2. Tam VC, Knowles SR et al. CMAJ 2005;173(5):510-5
3. Cornish PL, Knowles SR et al. Arch Intern Med 2005;165:424-9
4. Gazarian M, Graudins LV. Pediatrics 2012; 129: e1334–1342.
5. Gleason KM, Groszek JM et al. Am J Health-Sys Pharm 2004;61;1689-94
6. Duguid MJ, Gibson M et al. J Pharm Pract and Res 2002; 32: 94-5
7. Runciman WBW, Roughead EEE et al. Int. J. Qual. Health Care 2003; 15: i49–59. 5
Question 2:

When considering the consequences from

medication errors, are children (compared to
adults) at?
A. Increased risk of harm
B. Decreased risk of harm
C. Similar risk of harm
D. No risk

Submit your response: PollEv.com/nicolettegra067

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Medication Safety in Children
• Medication errors in hospitalised children occur at similar rates to adults (4.3-5.7% of orders)
– But errors with potential to cause harm were THREE TIMES more likely to occur
– Prescribing errors most common
– Neonatal ICU particularly susceptible
Fortescue EB et al, Paediatrics 2003:111:722-729
Why are Children at an increased risk of adverse drug events?

• Different and changing pharmacokinetic and

pharmacodynamic parameters
– Immature organ function to metabolise
drugs

• Lack of suitable paediatric preparations (need

for dilution/manipulation)
– Need for precise dose measurement and
appropriate drug delivery systems

• Off label prescribing/lack of published

information

• Need for calculation of doses - age, weight,

BSA and condition - 10 fold errors

• Communication ability compared to adults

Kearns GL et al. NEJM 2003; 349: 1157-67

High Risk Medications (A PINCH)
Ten-fold errors
• Calculation errors
• Omitting decimal point (5mg vs 0.5mg)
– Oxycodone
• Incorrect unit (milligram vs microgram)
– Clonidine – 1000-fold overdose
– Error prone abbreviations (µg vs microg)

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Question 3:

Which analgesia would you consider safe for use

in children after adeno-tonsillectomy?
A. Paracetamol and Oxycodone (alternating)
B. Paracetamol/codeine combination product
C. Ibuprofen
D. None of the above

Submit your response to: PollEv.com/nicolettegra067

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 Codeine
FDA safety review identifies 10 fatal cases of
respiratory depression
• The FDA safety review identified 13 cases of respiratory depression in children aged from
21 months to 9 years — 10 fatal cases and three life-threatening cases.
– 8 cases occurred after adenotonsillectomy
– 3 occurred in children treated for a respiratory tract infection
– 1 nursing infant whose mother was an ultra-rapid codeine metaboliser also died.
Australia's Database of Adverse Event Notifications (DEAN) contains 14 cases of respiratory
depression in people taking a codeine-containing medicine, including five fatal cases.
Caution:
• Children with obstructive sleep apnoea may be particularly sensitive to codeine-related
respiratory adverse effects.
• Ultra-rapid metabolisers (increased expression of CYP2D6 enzyme) - convert more codeine
into morphine and are at increased risk of adverse events such as morphine toxicity
• Extensive (normal) codeine metabolisers are also at risk of respiratory depression
U.S. Food and Drug Administration. FDA Drug Safety Communication: Safety review update of codeine use in children; new
Boxed Warning and Contraindication on use after tonsillectomy and/or adenoidectomy.
2013..fda.gov/Drugs/DrugSafety/ucm339112.htm (accessed 19 October 2016).
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Meet Ruby (10kg)

• Previously well 14 month old girl

• Gastroenteritis and fever
• Mother took her to a peripheral hospital
• Child admitted overnight for rehydration
• No further vomiting the following day
• Blood cultures negative after first 24 hours
• Seen by junior doctor before discharge
• Gave general advice about hydration
• Advice regarding fever written down for
Mum:

Give 5mL paracetamol four times per day

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 Paracetamol
• Child initially seemed to improve and then after Paracetamol
a few days started vomiting and became listless 100mg/mL • For 10kg child
• Recommended
• Several more presentations to GP and visits to dose:
community pharmacy (supply of Panadol ®) • 15mg/kg/dose
every 4 to 6
• Upon further presentation to hospital, Doctor hourly
asked Mum about child’s medications, including • Dose: 1.5mL
OTC & complementary medicines (=150mg)
• Mum removed Panadol® 100mg/mL bottle from
handbag
– Administering 5mL (=500mg) four times a
day for 3 days (200mg/kg/day for 3 days) Paracetamol
– Recommended dose: Max 90mg/kg/day 24mg/mL • For 10kg child
• Recommended
• Bloods collected, liver enzymes markedly dose:
elevated and coags abnormal • 15mg/kg/dose
every 4 to 6
• Contacted Poisons Information Centre for
hourly
advice
• Dose: 6.25mL
• Child admitted to PICU with severe liver (=150mg)
impairment requiring N-Acetylcysteine

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Error prevention strategies
Medication histories
ASK LOTS OF QUESTIONS…DOCUMENT THE ANSWER…
• Prescription medicines • Topical medicines

• Inhalers, puffers, sprays • Inserted medicines

• Oral contraceptives • Injected medicines

• OTC medicines (remember: baclofen pump, insulin

pumps)
• Analgesics
• Recently completed medicines
• Gastro drugs
• Other people’s medicines
• Complementary medicines
• Social and recreational drugs
• Intermittent medicines (eg weekly)
Tip: “Show and tell”
Demonstrate dosing and write • Rescue medicines
down instructions – then ask
parent/carer to demonstrate
Immunisations
• With the exception of clean water,
immunisation is the most cost effective
health prevention activity world wide (WHO)
• No Jab No Pay legislation
– Improve immunisation rates in children
across Australia
– Reduce the incidence of vaccine
preventable diseases

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 Immunisations – prescribing pitfalls
• Rotavirus vaccine
• Only orally administered vaccine on National Immunisation program schedule
• Errors
– Wrong route of administration – Rotavirus vaccine given as IM injection, instead of ORALLY
o Other vaccines due at 2,4,6 months of age all administered via IM injection
– Timing of doses
o 1st dose can be given as early as 6 weeks of age, but no later than 12 weeks of age
o 3rd dose should be given before 32 weeks of age
o Due to increased risk of intussusception

Upper age limits for dosing of oral rotavirus vaccines (From Australian Immunisation Handbook (10th ed) )

Age of routine Recommended Recommended Recommended

Minimum interval
Doses oral age limits for age limits for age limits for
between doses
administration dosing - 1st dose dosing - 2nd dose dosing - 3rd dose

RotaTeq (CSL
3 oral doses 2, 4 and
Limited/Merck 6–12† weeks 10–32† weeks 14–32† weeks 4 weeks
(2 mL/dose) 6 months
& Co Inc)

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Immunisations – prescribing tips
Prevenar 13 ® vs Pneumovax 23®
• Minimum interval between doses:
– 8 weeks (if Prevenar 13 ® given first, then Pneumovax 23 ® 8 weeks later)
• If Pneumovax 23 ® is administered 1st – delay Prevenar 13 ® dose by 12 months
– Increased risk of fever/ adverse event

Immunisation history taking and advice for medically at risk patients

Taking an accurate history can be tricky!
– Useful resources
Paediatric Personal “Red book”
– VIVAS vaccination record
– ACIR (AIR)
– Public health unit
New- Queensland Specialist Immunisation service (QSIS)
• Available for complex paediatric immunisation questions.
• To contact a QSIS for immunisation advice please call 3068 1111 (LCCH switch) to
be redirected to one of the paediatric immunisation specialists.
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Antimicrobial Resistance (AMR) – a Global Threat
 What about Australia?
• National Antimicrobial Resistance strategy 2015-
2019 launched
• National surveillance: AURA project
• Australia: 24 DDD per 1000 population per day

11 DDD per 1000

population per
day

* Data refer to all sectors (not only primary care).

Source: OECD Health Statistics 2013, http://dx.doi.org/10.1787/health-data-en, IMS for United States
 Paediatric
Antimicrobial Stewardship
How?

Optimising antimicrobial use

• Antibiotic use guidelines • Immunisation

• Prescribing awareness:
• Dosing, route, duration
• Pharmacy review
• Microbiology antibiograms
• ID knowledge/consults
• Improving sanitation &
hygiene
• Surveillance of infections
• Improving diagnosis
• New diagnostic tools:
non culture techniques
• New antibiotics
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 NEW Mobile friendly
Paediatric Antimicrobial Stewardship (AMS) website
http://www.childrens.health.qld.gov.au/health-
professionals/ams

Now you can access up to date antimicrobial prescribing

and infection management guidelines from the comfort of
your own mobile device

• Paediatric infection management information

• Including paediatric antibiotic dosing
recommendations
• Improved navigation and search functionality
• Compatible with iOS and android devices
• Download to your mobile device homescreen
Paediatric Medicine Information
• Australian:
– AMH CDC (available online)
• International:
– UK: British National formulary for
Children (BNFc) (available online)
– US: Paediatric and neonatal dosage
handbook
• Your friendly pharmacist!
• Queensland Poisons Information centre
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Tips for Safe Prescribing in children
• Use Paediatric Medicines information resources
– Consider patient’s age, PKPD changes
– Check calculations carefully, and double check
– Optimize dosing (especially with antibiotics)
– Appropriate selection of antibiotic, route and length of treatment can
improve quality of care
• Involve the family/parent/carer and child in treatment choices
wherever possible
– Comprehensive medication and immunisation history
– “Show and tell” – assist families to safely and reliably manage
medicines at home
– Consider volume and palatability of oral medicines
o Your pharmacist might have some handy hints for making bad tasting
medicines taste better
• Document all Allergies/suspected adverse medication events
• Take care with high risk drugs: PINCH-A
 Thank-you
for your attention
and
have fun working with kids
Questions