How Drugs Are Administered to Pediatric Patients Essay

Question 1. How are biopharmaceuticals distributed and how does this relate to drug administration? 100-words

Question 2. Explain how drugs are administered to pediatric patients and how these methods would differ in an adult patient. 100-words How Drugs Are Administered to Pediatric Patients Essay

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Of all the ways that pediatric patients can be harmed during treatment, medication errors are the most common 1 and the most preventable. 2 When medication errors occur, pediatric patients have a much higher risk of death than do adults. 3 Evidence suggests that for each medication error that harms an adult patient, there are 100 undetected errors. Approximately one in every 100 medication errors results in what is known as an adverse drug event, in which a patient is harmed or dies as a result. 2 Considering how many inpatient medication orders and outpatient medication prescriptions are written each day, the number of pediatric medication errors is likely to be staggering.

As research results emerge, we are beginning to understand the impact of medication errors on children. Several studies of pediatric inpatients found rates of medication error ranging from 4.5 to 5.7 errors per 100 medication orders, 4 rates similar to those found in studies of adult inpatients. 5 Horen and colleagues found that pediatric outpatients had three times the risk of an adverse drug reaction, compared with adult outpatients, especially when the medication was used for an “off-label” indication-a common practice in pediatrics. 6 While this study found significant error rates, the frequency of pediatric medication errors in ambulatory settings may be greater, because there are fewer checks and balances in place to prevent them. According to Miller and colleagues, “Pediatric patient safety in ambulatory care settings should be a high research and policy priority given the unique vulnerabilities of children, the glaring lack of current knowledge, and the disproportionate reliance on ambulatory care as compared to inpatient care.” How Drugs Are Administered to Pediatric Patients Essay

Medication errors take many forms, but they don’t all result in injury or death. Medication errors are defined as the preventable, inappropriate use of medications that may occur at any stage of the medication process, including ordering, transcribing orders, dispensing, administering, and monitoring. In some instances, medication errors result in an adverse drug event. Adverse drug events can also occur at any step in the medication process.5, 8, 9

TYPES OF MEDICATION ERRORS
Bates and colleagues, among others, have demonstrated the phases of the care process in which medication errors are most likely to occur.10 In pediatrics, the prescribing or ordering phase is associated with the most errors-usually dosing errors-followed by the administering phase.11 According to research recently published in AJN, “When respondents to [a] staff patient-safety survey were asked to identify which profession has primary responsibility for ensuring patient safety, 96% of nurses and more than 90% of physicians, administrators, and pharmacists assigned primary responsibility to nurses,” regardless of the factors that contributed to the error (see “An Error by Any Other Name,” June 2004).12 Therefore, nurses involved in the care of children must be well informed about their patients and the medications ordered.How Drugs Are Administered to Pediatric Patients Essay

Contrary to earlier research,13, 14 nurses play a significant role (specifically in medication administration) in pediatric medication errors. 5 Even though many errors are caught before a drug is administered,15 medication errors not caught or intercepted by nurses can result in an adverse event. Because nurses are the ones who predominantly administer medications to patients, they are often the last potential barrier between a medication error (such as the wrong medication given at the wrong time) and serious harm. Nurses have a responsibility to ensure that patients receive the right medication at the right time, and to monitor patients after they’re given or have taken the medication to observe possible adverse events.How Drugs Are Administered to Pediatric Patients Essay

THE UNIQUE NATURE OF MEDICATIONS FOR CHILDREN
Children and adolescents are at greater risk than adults for medication errors because they have an immature physiology as well as developmental limitations that affect their ability to communicate and self-administer medications. Another important factor is that the great majority of medications are developed in concentrations appropriate for adults; therefore, pediatric indications and dosage guidelines often aren’t included with a medication, necessitating weight-based dosing or dilution.16 That is, in order for many drugs to be used in children, safe dosages-which are fractions of those normally given to adults-must be calculated. Determining pediatric dosages can be complicated because of the need to calculate them according to the child’s weight; therefore, those children who take such medications are at greater risk for medication error than others who take medications that don’t require such calculations. If no calculation is required, the risk of an error decreases significantly.How Drugs Are Administered to Pediatric Patients Essay

Research has identified some of the children most vulnerable to medication errors, including those

* who are younger than two years.17

* who are in ICUs, especially neonatal ICUs.4, 18, 19

* who are in EDs, especially if seriously ill, between the hours of 4 AM and 8 AM or on weekends.20

* who are receiving chemotherapy.21

* who are receiving IV medication.21, 22

* whose weight hasn’t been documented.23

Many of the medications of benefit to children in emergency situations and in the treatment of certain diseases have been approved by the Food and Drug Administration (FDA) only for use in adults.24 Testing of these medications in children has been thwarted by several barriers inherent to research in children (for example, ethical concerns about using children as clinical trial subjects, the necessity of obtaining parental consent, and the difficulty of enrolling a sufficient number of children). However, the majority of medications used in neonates25, 26 and children who need chemotherapy20 are off-label (sometimes called unlicensed) medications, because the majority of medications FDA approved for children don’t offer many of the therapeutic benefits of off-label medications. It’s safe to use an off-label medication in a child only when its use is fully understood by all clinicians who treat the patient.24 Because most medications don’t carry information on child-related dosing guidelines, adverse effects, or safety and efficacy information, using medications in off-label applications-that is, without FDA approval for children-puts children at significant risk for error.How Drugs Are Administered to Pediatric Patients Essay

WHAT’S THE RIGHT DOSE FOR A CHILD?
Giving an adult dose to a child without considering the child’s weight, age, and clinical condition can cause an overdose and may result in toxicity and death. The most commonly used methods for calculating pediatric doses involve determining a fraction of an adult dose. Such calculations have been used by pediatricians nationwide for more than 50 years and may be used in children 12 years of age and younger and in those weighing less than 40 kg.28 (While the calculations are necessary to convert adult doses to safe pediatric doses, it’s important to note that the calculated fraction of the adult dose may not be safe for a particular child, given his health condition, status, and physiology.)

* Weight-based method. The following equation can be used to calculate a pediatric dose based on the child’s weight in kilograms:EQUATIONThe FDA also includes weight-based dosing recommendations for specific medications at http://www.fda.gov/cder/pediatric/labelchange.htm.How Drugs Are Administered to Pediatric Patients Essay

Equation U1 – Click to enlarge in new window Equation U1
* Body-surface area (BSA). A nomogram is used to determine dosage based on the actual size of the child, using the child’s height in centimeters and weight in kilograms. A straight line drawn across the nomogram from the child’s height (in the left column) to the child’s weight (in the right column) will intersect the BSA column (center) at a point indicating the child’s approximate BSA in square meters (m2). Then use the following equation to calculate the pediatric dose:EQUATIONThis method assumes that the glomerular filtration rate is proportional to BSA. The glomerular filtration rate (which is an indication of how well the kidneys are able to excrete the medication) can be used as an index of filter integrity in patients three years of age and older.29, 30 This kind of dosage calculation is often used with medications that have a low therapeutic-toxic ratio, in which the rate of excretion is important in achieving the correct therapeutic effect, as in chemotherapy.How Drugs Are Administered to Pediatric Patients Essay

Equation U2 – Click to enlarge in new window Equation U2
* Status of prematurity. When calculating dosages of medications to be given to premature newborns (infants born at less than 30 weeks’ gestation), special consideration is given to their unique physiologic characteristics, including low gastrointestinal motility, high levels of extra-cellular body water, low total body fat composition, and decreased plasma protein binding. Essentially, this results in much smaller doses for premature infants than would be given to other infants.

* Dilution. Dilution is used when adult doses of liquid preparations of medication are available, from which a pediatric dose must be prepared. The general rule is to divide the desired amount of medication by the amount of medication in the available liquid preparation, and then multiply the result by the available amount of liquid preparation. For example, suppose you’re given an order for a child to receive 120 mg of penicillin, and the liquid preparation that’s available contains 200 mg of penicillin in 5 mL of liquid. How many milliliters should be given? Cross-multiply the following:EQUATIONThis yields the folowing proportion:EQUATIONThen solve for x by dividing both sides of the equation by 200:EQUATIONTherefore, x = 3 the pediatric dose is 3 mL.Formulas such as these shown above are especially useful when a child weighs less than 40 kg. Pediatric dose calculations employing units such as milligrams per kilogram of body weight or milligrams per square meter of BSA require an accurate weight in kilograms, not pounds. As children gain or lose weight and as their bodies mature, pharmacokinetics change; dosing must reflect these changes. It’s critical to monitor and document weight changes and the child’s age, as well as responsiveness to the drug therapy.How Drugs Are Administered to Pediatric Patients Essay

Equation U3 – Click to enlarge in new window Equation U3

Equation U4 – Click to enlarge in new window Equation U4

Equation U5 – Click to enlarge in new window Equation U5

Several important exceptions or caveats apply to any conversion formulas used. For example, standing orders for ibuprofen (Advil and others) or acetaminophen (Tylenol and others) to reduce fever assume that the correct dose for a particular patient will be determined by the patient’s weight in kilograms multiplied by the suggested amount of the medication in milligrams per kilogram. Unfortunately, errors can be made when a clinician calculates dosages for patients weighing 40 kg or more, the threshold at which an adult dosage can be considered, and the standard pediatric-dose conversion formulas become less useful. Clinicians should adjust the dosage according to the patient’s illness and overall medical condition, such as the presence of diseases affecting metabolism of the drug.How Drugs Are Administered to Pediatric Patients Essay

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A system of checks and balances should be instituted in every facility, but that has not been the case. The Institute for Safe Medication Practices reported on a survey of health care workers it conducted in 2000.32 Only about half of all respondents said that a pharmacist always recalculates a drug dose before filling an order or that the child’s weight in kilograms has been entered into the pharmacy computer before the drug is given out.

Technologic advances, such as computerized physician order entry with clinical decision support and bar coding, can decrease, if not eliminate, errors.16, 33(Clinical decision support software provides clinicians with comprehensive reference information on medications, such as dosing parameters and recommendations, potential drug interactions, and known side effects.) Computerized physician order entry can help prescribers determine the therapeutic medication dose using weight-based calculations, thereby eliminating human miscalculations and providing a warning if the attempted dose is too large or small, or if there’s a potentially harmful medication interaction or allergy.How Drugs Are Administered to Pediatric Patients Essay

MATHEMATICAL MISCALCULATIONS
As noted above, almost all pediatric medications require the clinician to perform a mathematical calculation, one that may be complex. The most common calculations involve fractions, percentages, decimals, and ratios. In mathematical tests, new interns and nurses have been found to have poor mathematical skills-nurses more so than physicians-and pharmacists have demonstrated the best computational skills.35-37 The inability to calculate the correct therapeutic volume of a drug dose accounts for the majority of pediatric medication errors.38 Research has found that the major problems behind many of these miscalculations are associated with

* an inability to conceptualize the right mathematical calculation to be performed39 and understand the mathematical process leading to the solution.40 For example, to be able to give doses listed as “mg per kg,” a nurse would need to first calculate the dose and then the volume to be given, based on the concentration available in stock. Using amoxicillin (Amoxil and others) as an example, if the order reads “Administer 20 mg per kg of amoxicillin every 12 hours” for a child who weighs 15 kg, the nurse would multiply 20 mg by 15 (kg) to arrive at a dose of 300 mg. The medication is supplied in a suspension of 250 mg per 5 mL. The nurse would then have to make a further calculation to know how many mL of medication to give the patient (6 mL).How Drugs Are Administered to Pediatric Patients Essay

* a lack of math skills needed to solve the problem,41 specifically, the use of fractions, percentages, decimals, and ratios.42

* infrequent use of calculation conventions in practice36, 37 and inexperience in applying these calculations in the clinical setting18, 19-both common among those who haven’t used these calculations since school. While these studies involved physicians, nurses must be able to perform the same calculations. If they can’t, they shouldn’t administer the medication.

Misplacement of the decimal point is a common dosing error that can lead to a tenfold error in overdosing or underdosing.43 The consequences of such errors include transient renal failure, tachycardia, respiratory failure, and cardiac arrest.35 Because dosage calculations for small children are dependent upon the use of a decimal point for accuracy, tenfold medication errors are more likely to occur.19 It’s important to note that some research has found that those who make tenfold calculation errors are also more likely to cause other medication errors.44 Some errors of this type have been linked to performance on calculation tests because those who perform poorly on such tests are more likely to make a mistake in practice, especially when fatigued or distracted.How Drugs Are Administered to Pediatric Patients Essay

There’s nothing worse than seeing a sick infant or child.

As caregivers, it takes a very special set of clinical and bedside skills to deal with challenges faced by pediatric patients and their immediate families.

Pediatric nurses are RNs who care for children of all ages in a variety of healthcare settings. All nursing students learn about pediatrics through formal classes and guided clinical experiences, but to specialize, a nurse typically applies to work in a site that serves pediatric patients. These facilities offer training and clinical experience directed to the unique characteristics of children.How Drugs Are Administered to Pediatric Patients Essay

Pediatric nurses are very knowledgeable about growth and development as they adapt their interactions and care to the individual child’s developmental level. In addition, pediatric RNs must acknowledge the experience of the family and collaborate with them to provide care for the child. Diseases, equipment, and treatments for pediatric patients are either different or vary in presentation from those of adults for children are unique, not miniature adults.

Having a Way With Kids

A natural rapport with children may be the most important reason to pursue a career as a pediatric nurse. Many pediatric nursing professionals have clever techniques for winning over their young patients. The ability to distract a child is perhaps as important as earning their trust, especially when you are administering immunizations or inserting IV lines. Often pediatric patients don’t understand why they are undergoing certain treatments, and having good rapport can help make unpleasant experiences a little easier for child patients.How Drugs Are Administered to Pediatric Patients Essay

Pediatric nurses also spend much of their time with concerned adults, the parents and relatives of young patients. Supporting these worried adults can be one of the most challenging aspects of the job, and also one of the most rewarding. Children often mimic an adult’s reaction or response to news. Therefore, keeping all parties calm and positive is important for the overall care of the child.

It takes a pediatric nurse with a great bedside manner to be there to provide care, support, guidance, and information to patients and families.

Getting Certified

Pediatric nurses continually add to their knowledge base by reading professional journals, participating in continuing education classes, and attending conferences such as those offered annually by the Society of Pediatric Nurses. After gaining experience, the pediatric nurse can take an exam to become a Certified Pediatric Nurse (CPN).How Drugs Are Administered to Pediatric Patients Essay

There are two organizations, Pediatric Nursing Certification Board, and American Nurses Credentialing Center, that support certification programs. Each one has an initial exam and subsequent requirements for continued certification. Maintaining certification is based on demonstration of continued knowledge acquisition.How Drugs Are Administered to Pediatric Patients Essay

Those who wish to continue their education and professional practice even further may pursue a Pediatric Nurse Practitioner (PNP) or Clinical Nurse Specialist (CNS) in Pediatrics. Masters in nursing (MSN) programs usually are two years in length for full time study or longer for part time study. After completion of the master’s degree, PNPs and CNSs apply to the state board of nursing for recognition as an advanced practice nurse and take their respective national exam for certification. Certification is required in many states and recommended in the others.

Pediatric advanced practice nurses serve as pediatric healthcare providers in primary or acute care settings for well and ill children from birth to 21 years of age. Examples of primary care sites include physician offices, school health, ambulatory, or outpatient clinics, surgical centers, and health departments. The acute care environment encompasses the pediatric inpatient, intensive care, and intermediate care units, the pediatric emergency room, same day surgery center, and pediatric rehabilitation facility.How Drugs Are Administered to Pediatric Patients Essay

Primary care PNPs have the additional knowledge and skill to diagnose and treat episodic illnesses; manage ongoing care of children with chronic conditions; and provide for a child’s health maintenance needs including well child examinations and developmental assessment. Acute care PNPs manage the medical, surgical, and nursing care for children during hospitalization in acute or intensive care settings. All PNPs practice in collaboration with physicians who provide protocols and are available for consultation or referral as needed.

CNSs function in a variety of settings in both the direct and indirect role. They model expert direct family-centered patient care. In addition, they influence care outcomes by providing education, expert consultation, and leadership in defining and implementing evidence-based practice for the staff. The Pediatric CNS may be identified in terms of a setting, a subspecialty, a type of care, or a type of patient ailment. They also work cooperatively with other disciplines to implement improvements in health care delivery systems.How Drugs Are Administered to Pediatric Patients Essay

Becoming a pediatric nurse can be a rewarding career choice for the right nursing professional. The opportunities pediatric nurses have to care for varying types of patients in varying settings and at varying levels are measureless. How Drugs Are Administered to Pediatric Patients Essay