A modified Delphi to define drug dosing errors in pediatric critical care

Area of Science:

• Pediatric Critical Care Medicine
• Clinical Pharmacology
• Medication Safety

Background:

• A globally accepted definition for dosing errors in adult and pediatric practice is lacking.
• Existing definitions of pediatric dosing errors exhibit significant variability in the literature.
• This variability complicates accurate identification and reporting of medication errors in critically ill children.

Purpose of the Study:

• To develop a clinician-based framework for defining drug dosing errors in critically ill children.
• To establish a set of guiding principles for identifying dosing errors.
• To determine consensus-based thresholds for what constitutes a dosing error across various drug classes and clinical scenarios.

Main Methods:

• A nationwide, three-stage modified Delphi method was employed from May to December 2019.
• Expert participants included Canadian pediatric intensive care unit (PICU) physicians, pharmacists, and nurses with at least 5 years of experience.
• Outcomes focused on underlying principles of drug dosing and agreed-upon error thresholds relative to a reference range.

Main Results:

• Forty-four experts participated, with high response rates across all three Delphi rounds (95%, 86%, 84%).
• Consensus was reached on 13 of 15 principles and 23 of 30 error thresholds.
• Key agreements included recognizing intercepted overdoses, under-dosing of critical medications, and dosing deviations of 50% or more as errors; however, a 10% deviation was generally considered an error threshold.

Conclusions:

• Defining dosing errors in pediatric critical care is complex, with expert clinicians expressing uncertainty in certain scenarios.
• For most intermittent medications, dosing outside a 10% range (above or below) was deemed an error, though context and drug properties were influential.
• This consensus-derived threshold aims to standardize clinical dosing, reporting, and enhance drug quality improvement initiatives in pediatric critical care.