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Infants are at the highest risk of getting the wrong medicine

WASHINGTON—The tiniest and youngest patients are at the greatest risk of harmful medication errors when facing surgery, according to a new study released Tuesday.

While 5 percent of all patients who experienced medical errors in the surgical arena were injured, nearly 12 percent of children who did were harmed, according to the report by U.S. Pharmacopeia, a private Maryland-based agency that sets industry standards for all the prescription drugs used in America.

For all patients, the study found that most errors involved painkillers and antibiotics, and typically included patients getting the wrong drugs or no drugs at all, or getting drugs at the wrong time or in the wrong amounts. Pharmacopeia said both types of medications should be targeted for risk-reduction measures.

The two most erroneously administered antibiotics were cefazolin and vancomycin, said Diane Cousins, the vice president of health-care quality information at Pharmacopeia and a co-author of the study. The painkillers morphine, fentanyl and meperidine were most likely to be provided in error.

The report blamed most medication errors on poor coordination and poor communication among medical staff members when surgery patients are moved from department to department.

"It's interesting to note that there is no single individual or role responsible for tracking the medication that should be administered to a patient as that patient is transported through this system," Cousins said.

The study, the largest review of its kind ever conducted, looked at more than 11,000 medication errors from more than 500 hospitals from 1998 to 2005. The report, which includes errors before, during and after surgery, found mistakes involving more than 700 medications. Of those, 165 medications were involved in harmful errors, with four resulting deaths, including one child.

Because the United States doesn't require clinical trials on a drug's effects on children—those trials test only on adults—dosages in youngsters and infants must be calculated by their weight.

Cousins said those calculations often aren't re-checked by anyone and involve converting pounds to kilograms, both of which increase the chance for error.

In addition, pediatric nurses appear to be unfamiliar with certain drugs for surgery patients and may seek information about them from outdated reference manuals.

The report defines a medication error as a preventable event that may cause or lead to inappropriate use of a drug or to patient harm. Patient harm is described as "the impairment of physical, emotional or psychological function or structure of the body and/or pain resulting therefrom."

Medication errors typically are reported on a voluntary basis at hospitals, and the response varies from institution to institution. Consumer advocates have lobbied for mandatory reporting, but industry leaders have opposed such mandates, arguing that they could backfire because the fear of professional and legal reprisals would cause staffers to underreport or ignore errors.

Nancy Foster, the vice president for quality and patient-safety policy at the American Hospital Association, said technology—such as bar-coding identification wristbands to ensure that the patient gets the right medication—held promise for improving error rates.

Cory Suzan Petty, a representative of the American College of Surgeons, said the organization hadn't had time to review the report and its findings.

U.S. Pharmacopeia made 47 recommendations to address the problems cited in the study, including:

_Improving communication among medical team members.

_Designating a pharmacist to coordinate medication safety for patients.

_Insuring that medications are administered on time.

_Calling on drug-makers to feature ready-to-use sterile packaging for drugs, especially those administered to children.

To help patients avoid medication errors, Pharmacopeia advises them to:

_Meet with their surgeons before the procedures and take necessary steps to prepare.

_Make sure they understand what's required of them before surgery.

_Bring lists of the prescription and nonprescription drugs they're taking on the day of surgery and advise surgical staff of any drug or food allergies.

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(c) 2007, McClatchy-Tribune Information Services.

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