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A modified Delphi to define drug dosing errors in pediatric critical care
Nadia Roumeliotis1,2,3, Eleanor Pullenayegum4,5, Paula Rochon6,7,8
1Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada. nadia.roumeliotis@gmail.com.
Insights
Defining pediatric drug dosing errors is complex. Experts agreed that dosing over 10% above or below the reference range is typically an error, guiding clinical practice and quality improvement.
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.
Background:
There is no globally accepted definition for dosing error in adult or pediatric practice. The definition of pediatric dosing error varies greatly in the literature. The objective of this study was to develop a framework, informed by a set of principles, for a clinician-based definition of drug dosing errors in critically ill children, and to identify the range that practitioners agree is a dosing error for different drug classes and clinical scenarios.
Methods:
We conducted a nationwide three staged modified Delphi from May to December 2019. Expert clinicians included Canadian pediatric intensive care unit (PICU) physicians, pharmacists and nurses, with a least 5 years' experience. Outcomes were underlying principles of drug dosing, and error thresholds, as defined by proportion above and below reference range, for common PICU medications and clinical scenarios.
Results:
Forty-four participants met eligibility, and response rates were 95, 86 and 84% for all three rounds respectively. Consensus was achieved for 13 of 15 principles, and 23 of 30 error thresholds. An over-dosed drug that is intercepted, an under-dose of a possibly life-saving medication, dosing 50% above or below target range and not adjusting for a drug interaction were agreed principles of dosing error. Altough there remained much uncertainty in defining dosing error, expert clinicians agreed that, for most medication categories and clinical scenarios, dosing over or below 10% of reference range was considered an error threshold.
Conclusion:
Dosing principles and threshold are complex in pediatric critical care, and expert clinicians were uncertain about whether many scenarios were considered in error. For most intermittent medications, dosing over 10% below or above reference range was considered a dosing error, although this was largely influenced by clinical context and drug properties. This consensus driven error threshold will help guide routine clinical dosing practice, standardized reporting and drug quality improvement in pediatric critical care.
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