Health

In September 2002, four-year-old Ryan Lucio was being treated at Ottawa’s Children’s Hospital of Eastern Ontario (CHEO) for a rare form of cancer. He died after doctors miscalculated his dose of the chemotherapy drug Interleukin II. Most drugs are administered based on a patient’s weight. Interleukin II, an experimental cancer treatment, requires a calculation based on body surface area.

The fatal error was missed by more than a dozen medical professionals checking Ryan’s meds. While the case is still under internal review at CHEO, it’s a terrifying example of how vulnerable children are to medication mistakes.

The wrong drug can be given. Two drugs, each innocuous, can cause harm when combined. Unclear instructions, confusing medication names, misread handwriting and miscalculation can all result in mistakes. These may include giving the right drug in the wrong amount or frequency, or administering the correct medication and dose through the wrong “route” — for example, by injection instead of intravenously.

In the last few years, Canada’s medical community has become increasingly concerned about medical errors of all kinds. “There’s a general recognition that medical error is a significant health problem, and that medication error is a significant part of medical error,” says professor of paediatrics Stuart MacLeod, executive director of the BC Research Institute for Children’s and Women’s Health in Vancouver.

A 1999 American report suggested such errors cause up to 98,000 deaths a year in the US — about 7,000 likely due to dosage mistakes. Here at home, the Canadian Institute for Health Information (CIHI) is examining the files of 20 hospitals in five provinces to determine the scope of medical error here — including medication errors. And another organization, the Institute for Safe Medication Practices Canada, is working on a smaller study of 15 Ontario hospitals.

“Dosage errors in kids are probably more common than in adults. Dosages used are often very small,” says Michael Rieder, a founding member of the Canadian Paediatric Clinical Pharmacology Network from London, Ontario. As a result, health-care professionals are more likely to make errors by using larger amounts, often because they incorrectly assume the smaller dose couldn’t be right. And, he adds, “there are staff who are mathematically inept. We’re actually studying that right now.”

A 2002 study of the emergency ward at Toronto’s Hospital for Sick Children found about 12 percent of some 450,000 dosages ordered “had some errors,” says hospital senior scientist Gideon Koren. Twenty of those were potentially harmful — ten times the medication needed was ordered — but 15 were caught before they were delivered. None of the five children who got the wrong doses were harmed, but “any level of error is too high,” says Koren. “Whether we can prevent it totally is another question.”

Some errors can be chalked up to stress and overwork in busy hospitals where, says John Millar, vice-president of research and population health for the CIHI, “nurses are routinely asked to work double shifts. Doctors are routinely up all night and then have to do surgery the next day.”

Some mistakes result from inconsistent, old-fashioned medication-ordering systems prone to human error. “More and more, there’s a demand for bringing computerized entry into the process,” notes Millar. He says less error-prone aids, such as computerized labels, storage and unit dosing, are not yet being applied uniformly. “Computerized order entry requires considerable investment, so not all hospitals have done it.”

At Sunnybrook and Women’s in Toronto, Edward Etchells heads the patient safety service, which does use computer systems to coordinate hospital procedures. He says parents can help ensure their kids aren’t given improper doses by asking the right questions. “Every physician’s goal is to make sure the child gets the correct treatment,” he says. “The informed parent is a fundamental component of a safe system. Asking questions is crucial to that. Ask, ask, ask.”

That mantra is chanted by physicians across the country, but some may not practise what they preach. If answers aren’t forthcoming, persist politely. If you have repeated trouble getting information, most hospitals have complaint mechanisms or patient advocates or ombudsmen on staff. Use them. Doctors can sometimes think of themselves as gods, and patients often revere doctors too much, says Millar. “That’s one of the things that will have to change, obviously.”

“Be vigilant,” adds Stuart MacLeod. “When the nurse comes in to add a medication to an IV or set up an infusion pump, ask: ‘What is that? What are you doing?’ Every so often it’ll turn out the drug is for the kid in the next bed or the next room.” Ideally a parent or other responsible relative should be with the child all the time, he says. “Nobody else is going to be as vigilant in looking after the interests of your child as you.”

That vigilance should extend to prescriptions and over-the-counter drugs as well, he adds. Drugs are approved for over-the-counter use because they have wide margins of safety, but dosing information can be sketchy. Some recommend doses by age, others by age and/or weight, notes Etchells. Some manufacturers are addressing the ambiguity and adding more information to packaging.

And parents should never assume natural products are safe just because they’re natural, notes Rieder. They can be as toxic as chemically formulated drugs.

Doctors also caution parents to be sure they understand the details about their child’s drug information clearly and in context, whether it comes from the doctor, pharmacist, label — or the Internet. “There’s variable quality control on the information on the Internet,” points out Etchells. Even on sites related to medical associations, where facts are far more likely to be accurate, parents could panic reading endless lists of extremely rare side effects. He advises viewing “all that information as subject for discussion” with the child’s doctor instead of panicking over what could be inaccurate.

In the end, he adds, “you can’t prevent everything.” Parents cannot hover over medical staff while experimental chemotherapy medication dosages are calculated. They cannot stand in operating rooms interrogating anaesthetists or surgeons. “We’ll never have zero risk,” notes Millar. “We don’t have zero risk in any aspect of life.”

While parents play an important role in patient safety, adds Etchells, they shouldn’t feel alone in their efforts to ensure their child gets adequate care. “I think parents have to remember that every physician’s goal is to make sure the child gets the correct treatment.”

Originally published in Today's Parent, June 2003