MGHfC Pediatric Medication Administration Process
| Synopsis: This article by Kathryn A. Beauchamp, RN, clinical nurse specialist, Pediatric Intensive Care Unit, and Lois F. Parker, RPh, senior attending pharmacist, Department of Pharmacy, explains the development of the MGHfC Pediatric Medication Administration Process. |  Download MGHfC Pediatric Medication Administration Process |
MassGeneral Hospital for Children, along with the departments of Pharmacy and Biomedical Engineering, has undertaken a collaborative approach to medication safety. This effort involves eliminating the “rule of 6,” and implementing standard concentrations for vasoactive medications and continuous infusions.
Medication administration in the pediatric population differs greatly from that of adult patients because of the need for weight-based dosing and the resulting need for individual dose calculation. Pediatric patients are at greater risk of medication errors due to the required math and individual mixing of each infusion. Based on a 2001 study done at MGH and Children’s Hospital, 13% of medication errors occurred in the administration phase.
Because the majority of medications are delivered via continuous infusion in the Newborn Intensive Care Unit (NICU) and Pediatric Intensive Care Unit (PICU), the “rule of 6” method of preparation has been utilized for many years. The rule of six was originally designed to enable caregivers to easily prepare and titrate admixtures of vasoactive medications. The concentrations are based on the patient’s weight, so that 1 mcg/kg/minute always equals 1 mL per hour. However, utilizing this formula for patients whose weights ranged from less than one kg to over 40 kg resulted in an unlimited number of drug concentrations. Since the Department of Pharmacy could not provide support for such a wide variety of concentrations, nurses were involved in preparation on the units.
Prior to 2004 JCAHO included minimizing the number of available concentrations of a given medication in its National Patient Safety Goals. The Joint Commission specifically included eliminating the “rule of 6” as part of this goal, with an implementation deadline of December 31, 2008. As part of a larger focus on patient safety, a multidisciplinary taskforce was formed to address this issue. This taskforce included members of the Department of Pharmacy, Nursing, Smart Infusion Pump Learning Lab (sponsored by the Sims Lab) and Biomedical Engineering. Project goals included: (1) eliminating the “rule of 6”; (2) establishing standard concentrations for continuous infusions; and (3) implementing smart infusion pumps with MGH approved drug libraries.
The benefits of using smart infusion pumps include the following: (1) drug libraries can be tailored to the patient population by weight categories; (2) soft minimum (meaning the recommendation could be over ridden) and maximum dosing for each drug that provides guidance to the clinician to prevent under-dosing or over-dosing; (3) hard minimum and maximum dosing (the recommendation is a fail safe and could not be over ridden) to prevent over-dosing of electrolyte solutions; and (4) bar code capabilities.
As a first step, team members visited the Albany Medical Center to review their medication delivery system, focusing on their weight-based standard drug concentrations and administration guidelines. Considering that we would be providing standard drug concentrations for patients weighing less than 1 kg, as well as children who were fluid restricted, the group recommended that a patient’s weight no longer drive mixing calculations, rather, standardized mixes would be prepared and selected based on safe flow rates. As a result, weight profiles were identified for the pediatric drug library to guide the dosing parameters needed for the smart infusion pumps. These profiles are as follows: NICU micro-preemie less than 1 kg, NICU infant 1-5 kg, PICU infant 1-5 kg, PICU pediatric 6-21 kg, PICU above 21 kg, and PICU above 40 kg.
Since pump flow rates of at least 0.3 mL/hour provide optimal titration, standard drug concentrations were developed, using patient weights ranging from 0.5 kg to over 40 kg. Nat Sims, MD, from Smart Infusion Pump Learning Lab, developed the MGH Pediatric Medication Administration Process Manual for Syringe Infusion Pumps with mixing guidelines and flow rates. This manual contains: (1) the pediatric drug library; (2) mixing guidelines and flow rates for each drug and concentration: (3) IV administration guidelines for each drug, starting dose, bolus or loading dose and continuous dose by drug; (4) usual and maximum dosing by drug; and (5) pump flow rates by drug concentration, dose rate and patient weight. Color zones, based on traffic signals of green, yellow and red, were developed to assist the clinician in choosing the concentration associated with optimal flow rates. This method of pediatric medication administration is so progressive that the manual has been copyrighted and affiliates are expressing a great deal of interest in implementing this new program.
Team members completed the initial project goals in the summer of 2005. Standard drug concentrations and smart infusion pumps using the MGH pediatric drug library were implemented in the NICU and PICU in September 2005 and the cardiac OR in October 2005. Future goals include expanding the use of the smart pumps and pediatric drug library to all inpatient areas caring for pediatric patients, including the ED, operating rooms, and cardiac cath lab and evaluating outcomes of this implementation.
We would like to thank the members of our taskforce for their hard work and commitment during the past two years: Co-chairs Brenda Miller, RN and Ray Mitrano, MS, RPh, Project Manager from Biomedical Engineering Gayle Fishman, RN, Pediatric Pharmacist Lisa R. Morlitz, Mary Wyszynski, RN, of the NICU, and Ellen Kinnealey, RN and Nat Sims, MD, of Biomedical Engineering.
