Pediatric medical errors part 2: case commentary. A source of tremendous loss

The Dowdell (2004) case report chills the reader. We must learn through its publication methods of prevention of medication error. The attached guidelines provided by the ISMP can lead us in a more cautious direction. Knowledge of the float regulations would have required that the involved hospital had ensured that a float nurse to pediatrics understood that medication dosages were weight dependent and that calculations were required prior to drug administration. Adequate staffing might have prevented the need for a float nurse and allowed for more attention to double checking calculations and drug administration. Dissemination of the guidelines from the AAP or those recommended by the SPN might have prevented this error. The age-old story of impoverished physician-nurse interaction has outlived its place in history. Nurse-physician collegiality and investment in the team approach will save children's lives.