Identification of the top-10 problematic pediatric medications

Objectives: This survey measured the consensus opinion of pediatric pharmacists on ranking medication categories from least to most problematic regarding patient safety, and the top-10 most problematic pediatric medications.

Methods: Participants ranked 11 medication categories as least, moderate and most problematic regarding patient safety. Participants also ranked the top-10 from a list of 50 medications for three areas: medication problems in dosing, adverse effects and medication errors.  Medications from each area were summed and ranked from 1 to 50 to identify the top-10 list. The 11 medication categories and 50 medications were drawn from expert consensus, the Institute for Safe Medication Practice (ISMP) high-alert medication list, and medication alerts/reviews of pediatric literature.

Results: The survey was completed by 10.7% (67) of 624 ACCP Pediatric Practice and Research Networks (PRN) pharmacist members.  Participants represent mostly clinical pharmacists (75%), working in children’s hospitals (61%) or pediatric units (25%), from 25 states and 3 Canadian provinces. Seventy-percent are members of the Pediatric Pharmacy Advocacy Group. Regarding overall pediatric patient safety, participants ranked anticoagulants as most problematic, anticonvulsants as moderately problematic, and gastrointestinal medications as least problematic.  The top-10 medications from first to tenth (including ties) were: 1-insulin, 2-warfarin, 3-heparin, 4-vancomycin, 5-(tied: digoxin & gentamicin), 6-potassium chloride, 7-morphine, 8-methadone, 9-(tied: fentanyl & potassium phosphate) and 10-calcium chloride.

Conclusion: ACCP Pediatric PRN pharmacists identified nearly the same medications reported as problematic in other publications of pediatrics. Franke et al. in 2009 reported on a top-10 open survey that physicians, nurses and pharmacists ranked 1-potassium, 2-heparin, 3-insulin, 4-digoxin, 6-calcium, 8-morphine, and 9-fentanyl as high alert pediatric ICU medications. Harm from medication errors in pediatrics reported to ISMP Canada in 2009 ranked 1-morphine, 2-potassium chloride, 3-insulin, and 4-fentanyl in the top five medications. This survey’s consensus ranking by pediatric pharmacists is consistent with other healthcare professions.