SCIENCE AND PRACTICE

Journal of the American Pharmacists Association 56 (2016) 54e57

Contents lists available at ScienceDirect

Journal of the American Pharmacists Association

journal homepage: www.japha.org

RESEARCH NOTES
Evaluating the impact of a pediatric weight-based dosing
procedure in outpatient pharmacy
Jonathan J. Grant*, Morgan B. Adams, Krista Decker, Susan McFarland,
Carlton K.K. Lee

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To describe the percentage of pediatric outpatient pharmacy prescriptions with
Received 26 December 2014 inappropriate prescribing identied by a pharmacist that resulted in a change to the pre-
Accepted 1 August 2015 scription. Secondary objectives include describing types of inappropriate prescribing errors,
prevalence of Institute of Safe Medication Practices high-alert medications, patient de-
mographics, prescriber origin, and prescription origin.
Methods: This retrospective outpatient prescription record review was approved by an insti-
tutional review board and performed at an outpatient pharmacy located in an academic
teaching hospital. The study reviewed pediatric outpatient prescriptions for a 6-month period.
Prescriptions with prescribing errors were identied from pediatric prescriptions sent to the
problem queue and documented with appropriate pharmacist notes.
Results: This study demonstrated the impact of a dose checking procedure and pharmacist
interventions on pediatric prescriptions. Initial results show that 3% of all pediatric pre-
scriptions required a pharmacist intervention. Of these prescriptions, 50% resulted in a change
to the original prescription.
Conclusion: Weight-based dose checking in a pediatric outpatient pharmacy proactively pre-
vents potential adverse events among the pediatric population. Despite this study's limita-
tions, we believe that a pediatric dose checking procedure in community pharmacies will
reduce adverse events. Further study is warranted in this eld.
2016 American Pharmacists Association. Published by Elsevier Inc. All rights reserved.

Medication errors resulting from initial inappropriate pre-
scribing are common among the pediatric population, occur-
ring in as many as 15% of pediatric outpatient prescriptions.1,2
Medication errors in pediatric patients carry a signicantly
greater potential to cause harm than medication errors in the
adult population. Because of variations in sizes, children are
Disclosure: The authors declare no relevant conicts of interest for nancial
relationships for this study. A grant from the Johns HopkinseWalgreens
Clinical Committee was awarded to develop a standalone, pediatric, weight-
based dosing calculator for future research.
Funding: This study was not funded.
Previous presentations: American Pharmacist's Association Annual Meeting
Orlando, FL, March 28e31, 2014; Eastern States Conference for Residents and
Preceptors, Hershey, PA, May 6, 2014; Maryland Society of HealtheSystem
Pharmacy Research Week Baltimore, MD, May 19e23, 2014; Johns Hopkins
Medicine Safety Summit, Baltimore, MD, June 6, 2014.
* Correspondence: Jonathan J. Grant, PharmD, BCACP, Johns Hopkins
Outpatient Pharmacy, 5901 Holabird Ave Suite A, Baltimore, MD 21224.
E-mail address: jgrant24@jhmi.edu (J.J. Grant).
susceptible to 10- to 100-fold dosing errors.3 Accurate weight
and appropriate drug concentration and formulation are crit-
ical to prescribe and administer pediatric medications accu-
rately. Safe and effective dosing of medications for the
pediatric population is critical. Most outpatient community
pharmacies do not have a procedure to prevent pediatric
dosing errors. Subsequently, error prevention strategies in this
area are widely untested.
Compared with adults, children have signicant pharma-
cokinetic and pharmacodynamic differences, making them
more susceptible to medication errors.4 Previous studies have
shown that the majority of adverse drug reactions and medi-
cation errors occur at the time of physician prescribing, as 74%
of medication errors and 79% of adverse drug reactions
occurred at the stage of physician ordering, and that the most
frequent type of medication error was a dosing error.5,6
Although there are processes for limiting these initial dosing
errors for the inpatient prescriptions, there are limited studies
on medication errors and effective strategies for reducing

http://dx.doi.org/10.1016/j.japh.2015.11.004
1544-3191/ 2016 American Pharmacists Association. Published by Elsevier Inc. All rights reserved.

Outpatient pediatric weight-based dosing
patient harm in pediatric outpatient care.7 In an attempt to
reduce dosing errors among pediatric outpatient prescriptions,
in 2003, the Johns Hopkins Outpatient Pharmacies imple-
mented a pharmacist-initiated, weight-based dose checking
procedure for every pediatric (<18 years old) prescription.
The weight-based dose checking procedure at Johns Hop-
kins Outpatient Pharmacy mandates that two pharmacists
perform a dosing calculation and cite an appropriate reference
for each pediatric prescription. When a pediatric prescription
is encountered, the pre-verication pharmacist is responsible
for the weight-based dose calculation. The pharmacist refers to
an approved reference, such as Lexicomp, Up-to-date,
Micromedex, Harriet Lane Handbook, or the patient elec-
tronic health record to cite appropriate dosing, and then con-
ducts weight-based dosing. If there are any discrepancies
between the recommended and prescribed doses, the pre-
verication pharmacist sends the prescription to the problem
queue and performs a pharmacist intervention by contacting
the prescriber. The nal verication pharmacist double-checks
the calculation before allowing the prescription to be
dispensed to the patient.
Objectives
The primary objective of this project was to describe the
percentage of outpatient pharmacy prescriptions with inap-
propriate prescribing identied by a pharmacist that resulted
in a prescription change. Secondary objectives included
describing the types of inappropriate prescribing errors,
prevalence of Institute of Safe Medication Practices (ISMP)
high-alert medications, patient demographics, prescriber
origin, and prescription origin.
Methods
The study setting was the Johns Hopkins Outpatient Phar-
macy at the Arcade located near the Bloomberg Children's
Center at The Johns Hopkins Hospital, a tertiary academic
medical center. This pharmacy lls approximately 450 pre-
scriptions per day, of which approximately 30% of the pre-
scriptions are for pediatric patients. Approximately 60%-70% of
patients discharged from the Children's Center have their
discharge medications lled at the aforementioned outpatient
pharmacy.
A retrospective outpatient prescription record review was
performed for all pediatric prescriptions lled between July 1,
2013, and December 31, 2013, at the Johns Hopkins Outpatient
Pharmacy at the Arcade. Patients younger than 18 years were
considered pediatric patients. From these data, only pre-
scriptions sent to the problem queue because of the weight-
based dosing infraction were analyzed. The problem queue is
an electronic database in which prescriptions in the
dispensing process are held because of an issue that must be
resolved with the prescriber or patient insurance. Pre-
scriptions sent to the problem queue for any reason other than
weight-based dosing were excluded.
Prescriptions that met the criteria for inclusion were
described based on types of inappropriate prescribing. This
included overdosing, suboptimal dosing, inappropriate dosing
interval, and incomplete or illegible prescriptions. Prescriptions
were also analyzed to determine the error prevalence by ISMP
SCIENCE AND PRACTICE
55
high-alert drug classes. These classes include antiretroviral
agents, chemotherapeutic agents, immunosuppressant agents,
and opioids. Prescriptions were also analyzed to describe pa-
tient demographics of age, weight, and sex. The prescriber
origin was also analyzed to determine whether the prescriber
was house staff or not. A house staff prescriber is dened as
residents and fellows in training, and non-house staff pre-
scribers were categorized as attending physicians and physi-
cian extenders. Lastly, the prescription origin was described as
either computer generated or hand written. This study was
approved by The Johns Hopkins Medical Institutions Institu-
tional Review Board.
Results
Five thousand ten pediatric prescriptions were lled at the
Arcade Pharmacy between July and December 2013; 1448 (29%)
pediatric prescriptions were sent to the problem queue; 156
(3%) required pharmacist intervention because of the dosing
procedure; 78 (50%) of those prescriptions were changed
because of the pharmacist intervention. The majority of pre-
scribing errors resulting in pharmacist intervention were for
dose too high (59%) followed by incomplete, illegible (22%), or
inappropriate dosing interval (14%), and dose too low (5%).
There were 14 (9%) prescriptions for ISMP high-alert
medications that required pharmacist intervention. Among
these prescriptions, 8 (57%) prescriptions were opioids, 4 im-
munosuppressants (29%), 1 (7%) hypoglycemic agent, and 1
(7%) chemotherapy. Approximately 30% of patients with pre-
scription errors weighed less than 10 kg (Fig. 1). More than 50%
of prescribing errors occurred in children younger than 6 years
(Fig. 2). The majority of prescribers were house staff physicians
(67%). The majority of prescriptions requiring intervention
were hand written (77%).
Discussion
This study is one of the rst to describe a prevention strategy
for pediatric medication errors in outpatient pharmacies. This
research provides some insight on the impact of a standardized
weight-based dosing procedure. We identied that 3% of all
pediatric prescriptions prompted a pharmacist intervention
because of the weight-based dosing procedure. Interestingly,
50% of pharmacist-recommended interventions resulted in a
10 Kg
6% 15%
32% 11-20 Kg
21-30 Kg
12% 31-40 Kg
41-50 Kg
13% 22%
>50 Kg
Figure 1. Patient weight n156.
SCIENCE AND PRACTICE
56 J.J. Grant et al. / Journal of the American Pharmacists Association 56 (2016) 54e57
3%
Neonate (<1 month)
21% 19%
Infant (1 month to <1 year)
Young child (1-5 years)
26% Older child (6-12 years)
31%
Adolescent (13-17 years)
Figure 2. Patient age n156.
change to the original prescription. Interventions were rejected
for a variety of reasons, such as inappropriate dose for a patient's
illness or condition per hospital protocol, off-label dosing,
or clarication of an illegible prescription. Nonetheless, phar-
macist interventions could reduce pediatric medication errors
that are prevalent in outpatient pharmacies.
Opportunities to study the impact of pharmacist inter-
vention on antiretroviral agents, chemotherapeutic agents,
hypoglycemic agents, immunosuppressant agents, insulin,
opioids, and liquids that require measurement in the pediatric
population are needed. These medication classes have the
greatest potential for causing harm in this population. In this
study, opioids and immunosuppressant agents were the most
prevalent high-alert medication classes observed in this study.
Of the prescriptions requiring intervention, the majority were
for children weighing less than 20 kg (54%) and children 5 years
and younger (53%). In addition, the majority of prescribing errors
were for overdose (59%). Because prescriptions that were not
sent to the problem queue were not analyzed, we are unable to
draw conclusions on relationships between age, weight, pre-
scription origin, and prescriber origin of pediatric prescriptions;
however, further study is warranted in this area.
This weight-based dosing procedure can be applied to
other outpatient pharmacies. The most signicant challenge
will be obtaining the patient's weight from either the pre-
scriber or patient's parent or guardian before dispensing.
Currently, many providers do not routinely print patient
weight on the prescription. By instituting a standardized
weight-based dosing procedure across outpatient pharmacies,
this practice can be changed. Initially, there might likely be
increased calls to prescribers but over time, prescribing prac-
tices will adapt. Patient weight consideration will also build
trust between pharmacists and patients as it helps to further
individualize care. Pharmacies can also carry scales.
The pharmacist will also need access to appropriate drug
information to screen the prescription properly. Although the
weight-based dosing procedure in the study uses two phar-
macists to ensure proper calculations, the procedure could be
conducted by a single pharmacist or a pharmacist-intern
combination. The time needed to complete the weight-based
dosing procedure is signicant. On average at the study loca-
tion, it takes 2- to 2.5 times longer to complete this dosing
procedure compared to an adult prescription. There is a
glaring need for an efcient and easy-to-use electronic appli-
cation program that will make standardizing a weight-based
dosing procedure feasible in outpatient pharmacies; this, too,
can help to build pharmacist condence in properly screening
pediatric prescriptions. At a minimum, it should be used for
high-alert medications in the pediatric population. Ideally, it
should not signicantly increase time to ll and should prompt
prescriber contact when truly warranted.
Limitations
There are several limitations to this study; this was a
retrospective, single-center study. The procedure to collect
the data relied solely on prescriptions sent to the problem
queue. There are instances in which a pharmacist is able to
contact the prescriber and make changes to a prescription
without sending the prescription to the problem queue. This
example suggests that the data collected is likely an under-
estimation of the true number of prescriptions requiring an
intervention.
An additional limitation to this study is that the majority of
prescribers were house staff physicians from an academic
teaching hospital. In this setting, there is a learning curve
experienced by new prescribers in training. As a result, the
error rate of prescriptions in this study may be higher than at
other outpatient pharmacies. This may be due to the learning
curve experienced by new prescribers in training. Prescribers
may have also been more inclined to accept pharmacist in-
terventions in the environment of a teaching hospital. In
addition, the Johns Hopkins Outpatient Pharmacy at the
Arcade receives more pediatric and high-alert medications
compared with other community pharmacies, on the basis of
its location within an integrated health system.
As mentioned previously, a lack of a control group in
this study limits the conclusions that can be taken from
this study. Without a control group, patient demographics
are purely descriptive and leave opportunity for follow-up
and additional studies to determine what ages and weights
of patients are more susceptible to weight-based dosing
errors.
Conclusion
This study demonstrates the outcome of a pediatric
weight-based dosing procedure in an academic medical center
outpatient pharmacy by reducing prescribing errors in the
pediatric population. This study also highlights the success of
pharmacist intervention, as recommendations were accepted
by the prescriber 50% of the time. The weight-based dosing
procedure can be adopted by any outpatient pharmacy, and it
may proactively help to reduce medication errors for children.
Additional studies are warranted in this eld to dene the
potential impact of the pediatric weight-based dosing proce-
dure on prescribing errors and to identify specic pediatric
subpopulations at the greatest risk for harm.
Acknowledgments
The authors thank Nathan Thompson, MPH, Amy Nathan-
son, PharmD, BCACP, AE-C, and Denise Fu, PharmD, BCACP, for
guidance and professional support and Hsiao-Ting Wang,
PharmD, for assistance with data collection.

Outpatient pediatric weight-based dosing
References
1. Rinke M, Bundy D, Shore A, et al. Pediatric antidepressant medication er-
rors in a national error reporting database. J Dev Behav Pediatr. 2010;31(2):
129e136.
2. McPhillips HA, Stille CJ, Smith D, et al. Potential medication dosing errors
in outpatient pediatrics. Journal Pediatr. 2005;147(6):761e767.
3. Miller MR, Pronovost PJ, Burstin HR, et al. Pediatric patient safety in the
ambulatory setting. Ambul Pediatr. 2004;4(1):47e54.
4. Sard BE, Walsh KE, Doros G, et al. Retrospective evaluation of a comput-
erized physician order entry adaptation to prevent prescribing errors in a
pediatric emergency department. Pediatrics. 2008;122(4):782e787.
5. Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for
preventing medication errors and adverse drug events in pediatric in-
patients. Pediatrics. 2003;111(4 Pt 1):722e729.
6. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse
drug events in pediatric patients. JAMA. 2001;285(16):2114e2120.
7. Neuspiel D, Stubbs E, Liggin L. Improving reporting of outpatient pediatric
medical errors. Pediatrics. 2011;128(6):1608e1613.
SCIENCE AND PRACTICE
57
Jonathan J. Grant, PharmD, BCACP, Clinical Coordinator Pharmacist, Johns
Hopkins Outpatient Pharmacy, Baltimore, MD; at time of study, PGY-1
Community Pharmacy Resident, Johns Hopkins Home Care Group, Balti-
more, MD
Morgan B. Adams, PharmD, BCACP, Ambulatory Clinical Pharmacist, Palmetto
Health, Columbia, SC; at time of study, Clinical Coordinator Pharmacist, Johns
Hopkins Outpatient Pharmacy, Baltimore, MD
Krista Decker, RPh, MSQA, Medication Safety Ofcer, Johns Hopkins Home Care
Group, Baltimore, MD
Susan McFarland, MD, Pediatric Hospitalist, Johns Hopkins Bloomberg Chil-
dren's Center, Baltimore, MD
Carlton K.K. Lee, PharmD, MPH, FASHP, FPPAG Clinical Pharmacy Specialist,
Pediatrics PGY-2 Pediatric Pharmacy Residency Program Director Department of
Pharmacy, The Johns Hopkins Hospital; Associate Professor (Part-time), Pediat-
rics School of Medicine, Johns Hopkins University; and Clinical Professor, Depart-
ment of Pharmacy Practice and Sciences School of Pharmacy, University of
Maryland, Baltimore, MD