ANN ARBOR, Mich. — When children switch pharmacies, they may be at risk of prescription dosage errors, a survey of Michigan pharmacies found.
Now, a statewide initiative led by a University of Michigan team to reduce pediatric medication errors will make Michigan the first state to standardize concentrations for children’s liquid prescriptions.
U-M and the Michigan Pharmacists Association have announced the release of the new standards published on mipedscompounds.org as part of a sweeping campaign to educate prescribers and pharmacists in the state and rest of the country. The move comes after a survey of Michigan pharmacies revealed potential safety risks posed by the lack of standardization of compounded pediatric oral liquids for over 110 different medications in a variety of therapeutic categories.
In Michigan, more than half of the compounded drugs had at least three different concentrations being compounded by various pharmacies, with some concentration levels up to thirtyfold higher than others, according to information collected from more than 200 participating pharmacies.
“One of the greatest dangers associated with this variation is that children may switch pharmacies but continue to take the same volume as always – without parents or even doctors realizing that the drug’s concentration has changed and that a new dose volume should be prescribed,” says project lead James Stevenson, Pharm.D., FASHP, Chief Pharmacy Officer of the UMHS Pharmacy Services Department and an associate dean at the U-M College of Pharmacy. “
“The drastic differences in concentrations patients could receive depending on which pharmacy compounded their prescriptions were deeply concerning, and these uniform standards are essential for patient safety. We are urging all prescribers and pharmacies to follow our recommended standards to avoid potentially harmful medication errors.”
Children are often prescribed oral liquid prescriptions instead of hard-to-swallow pills, and medications that are not commercially available must be compounded by a pharmacist. Before the new recommendations, pharmacists were using different concentrations when compounding more than 100 drugs.
“Transitions in sites of care, including movement between the home and the hospital as well as between pharmacies, are associated with patient safety risks and this may be especially true in the pediatric population because of the number of liquid medicines that must be compounded,” says UMHS Pediatric Associate Chief Medical Officer Chris Dickinson, M.D., a co-investigator on the project.
"It has been gratifying to see this state-wide collaborative effort and we encourage all prescribers and pharmacists to adopt the standard concentrations in the interest of improving medication safety in our pediatric population.”
The initiative has prompted standard concentrations for nearly 120 drugs that are available on the new mipedscompounds.org website. The drugs on the list range from Adderall (used to treat narcolepsy and attention deficit hyperactivity disorder or ADHD) to Baclofen (a medicine that treats muscle spasms and tight muscles often used for children with cerebral palsy or multiple sclerosis).
The project was supported by a $150,000 grant from the Food and Drug Administration. The standards have been endorsed by the Michigan Academy of Physician Assistants, Michigan Health & Hospital Association, Michigan Pharmacist Association, Michigan Osteopathic Association and the Michigan State Medical Society.
The new standard concentrations can be found at http://www.mipedscompounds.org.