Overview of Pediatric Inpatient Medication Delivery

Abstract

The term “medication process” includes all aspects of the management of pharmaceuticals used in the care of patients: drug manufacture (creating, packaging, and assuring the quality and safety of medications for human use), pharmaceutical procurement (acquiring, storing, and managing medications for patient care), medication reconciliation (identifying, verifying, and realigning a patient's current drug regimen with the intended care plan when a change in medical care (admission, discharge, transfer) occurs) and medication use. Medication use is the process of prescribing, ordering, compounding, dispensing, and administering drugs, monitoring (and documenting) their effects on patients. It is the last aspect of which this section is an overview, and which is the focus of subsequent sections.

The complexity of each of the above-mentioned processes, within their respective complex environments (chemical manufacturing plants, pharmacies, hospitals, and clinics) makes medication processes inherently error-prone. Of these processes, the largest negative impact on patient health comes from errors in mediation use. Illegible handwriting, numerous human hand-offs of instructions, complex patient data, critical drug dose information and ever-changing formularies of drugs with varying degrees of potency and toxicity all contribute to the vulnerabilities and errors in medication use, and to the challenges of efficiently and safely managing them. Not surprising, adverse drug events (ADEs) result in more than 770,000 injuries and deaths each year in the US and cost up to $5.6 million per hospital.¹