AUTHOR BIOGRAPHIES
Jacqueline Russell, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
ORCID iD https://orcid.org/0000-0001-5145-8386
Jacqueline Russell is a research associate at the MedStar Health National Center for Human Factors in Healthcare and a general surgery resident at MedStar Health.
Joanna P. Grimes, BSN, RN, MedStar Health National Center for Human Factors in Healthcare
ORCID iD https://orcid.org/0000-0002-3835-7828
Joanna Grimes is a nurse researcher at the MedStar Health National Center for Human Factors in Healthcare.
Sofia Teferi, MD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
ORCID iD https://orcid.org/0000-0002-3361-7133
Sofia Teferi is a pediatrician and research physician at the Medstar Health National Center for Human Factors in Healthcare and an assistant professor at Georgetown University School of Medicine.
Zoe M. Pruitt, MedStar Health National Center for Human Factors in Healthcare
ORCID iD https://orcid.org/0000-0002-2749-9652
Zoe Pruitt is a senior human factors specialist at the MedStar Health National Center for Human Factors in Healthcare.
Jessica L. Howe, MA, MedStar Health National Center for Human Factors in Healthcare
ORCID iD https://orcid.org/0000-0003-1594-8171
Jessica Howe is a research scientist and system safety specialist at the MedStar Health National Center for Human Factors in Healthcare.Jessica L. Howe, MA,
Katharine T. Adams, MS, MedStar Health National Center for Human Factors in Healthcare
ORCID iD https://orcid.org/0000-0003-4826-8885
Katharine Adams is a data scientist at the MedStar Health National Center for Human Factors in Healthcare.
Natasha Nicol, PharmD, MedStar Health National Center for Human Factors in Healthcare
ORCID iD https://orcid.org/0000-0001-7563-564X
Natasha Nicol is a pharmacist at the MedStar Health National Center for Human Factors in Healthcare.
Seth Krevat, MD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
ORCID iD https://orcid.org/0000-0002-0167-8791
Seth Krevat is the senior medical director at the MedStar Health National Center for Human Factors in Healthcare and a faculty associate at Georgetown University School of Medicine.
Deanna Busog, BA, MedStar Health National Center for Human Factors in Healthcare
ORCID iD https://orcid.org/0000-0002-3480-5400
Deanna Busog is a senior research associate at the MedStar Health National Center for Human Factors in Healthcare.
Raj M. Ratwani, PhD, MedStar Health National Center for Human Factors in Healthcare, Georgetown University School of Medicine
Raj Ratwani is the director of the MedStar Health National Center for Human Factors in Healthcare, vice president of Scientific Affairs at the MedStar Health Research Institute, and an associate professor at Georgetown University School of Medicine.
Rebecca Jones, MBA, RN, Patient Safety Authority
ORCID iD https://orcid.org/0000-0002-6639-9312
Rebecca Jones (rebejones@pa.gov ) is the director of Data Science and Research at the Patient Safety Authority (PSA) and founder and director of the PSA’s Center of Excellence for Improving Diagnosis.
Ella S. Franklin, MSN, MedStar Health National Center for Human Factors in Healthcare
Ella Franklin is the senior director of Human Factors Nursing Research and Systems Safety at the MedStar Health National Center for Human Factors in Healthcare.
Abstract
Background:
Dose calculation errors are one of the most common types of medication errors impacting children and they can result in significant harm. Technology-based solutions, such as computerized provider order entry, can effectively reduce dose calculation issues; however, these technologies are not always optimized, resulting in potential benefits not being fully realized.
Methods:
We analyzed pediatric dose-related patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System using a task-analytic approach that focused on information being used in the dose calculation, calculation errors during ordering, and errors during dose preparation or administration. From these reports, we identified whether the patient was impacted by the error, the type of medication involved, and whether a technology optimization could have mitigated the issue.
Results:
Of the 356 reports reviewed, 326 (91.6%) met the criteria for a dose calculation issue. The 326 reports meeting criteria had the following dose calculation issue types: wrong information used in the calculation (49 of 326, 15.0%), incorrect calculation during ordering (97 of 326, 29.8%), and calculated dose was not properly used or incorrect calculation during preparation/administration (180 of 326, 55.2%). Most of these dose calculation issues impacted the patient (219 of 326, 67.2%). Analysis of these issues by patient age group and drug class also revealed interesting patterns. Technology optimizations potentially could have addressed 81.6% of the dose calculation issues identified.
Conclusion:
While many healthcare facilities have adopted health information technology and other devices to support the medication process, these technologies are not always optimized to address dose calculation issues. Human factors–informed recommendations, a safety checklist, and test cases for optimizing technology are provided in the context of these findings.
