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Impacts of Medication errors on 3-4-year-old Leukemia Patients

Submitted by

 

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

 

July 19, 2020

 

GRAND CANYON UNIVERSITY

 

Impacts of Medication Errors on 3-4-Year-Old Leukemia Patients

by

Bola Odusola-Stephen

Proposed

July 20, 2020

 

DPI PROJECT COMMITTEE:

Dr. Lisa Church, EdD, PhD, Manuscript Chair

Genevieve Onyirioha, RN, MSN, FNP, CMSRN, DNP, Committee Member

Table of Contents Chapter 2: 6 Literature Review 6 Introduction 6 Background 6 Theoretical foundations 8 Review of literature 10 Theme-1 Drug dispensation 10 Subtheme: 1 knowledge deficit 11 Subtheme 2: errors in written orders and formula conversations 11 Theme 2: Drug prescription 15 Subtheme1: errors associated with wrong prescription 16 Subtheme 2: errors associated with medical fillings 17 Theme 3: Parental administration and nurse administration 19 Subtheme1: Parental education on drug administration 19 Subtheme 2: error from ambulatory setting associated with lack of knowledge 22 Summary 28 References 29

Chapter 2: Literature Review

Introduction

Literature review will conduct views of scholarly article which will entail detail analysis of the information on medical administration errors in children between the ages of 3-4 years. The reviews will be formulated on the major areas of the PICOT question. Children aged 3-4 years have little power or control of their medication and are at great risk of encountering medial errors. The study subthemes will deal with drug prescription, parental administration and drug dispensation.

Background

Medication errors are the most common and the leading medical error in the United States. For a patient to appropriately receive the required treatment in a medical setting, there must be proper prescription of drugs, there is also the need for a pharmacist to effectively understand the doctors writing for them to be able to effectively prescribe the drugs. The nurses are also required to effectively administer the prescribed drugs (Khalek et al., 2015). Although various studies on in-patients show that the medical dispensing errors are also as common as those experienced in the in-patient setting. It is key to point out that in most of the inpatient settings, it is always the role of the patient or caregiver and rather than that of the healthcare professional. It for this reason to acknowledge the fact that potential for medication errors among the ambulatory patients is substantial. DNP- Direct Practice Improvement (DPI)

The major problem that has been identified with the medication errors for the young children that are undergoing chemotherapy and administered the leukemia drugs is of great significance (Mulatish, Dwiprahasto & Sutaryo, 2018). The leukemia drugs are by nature toxic and have low therapeutic windows and the results could be very disastrous when an error occurs during its administration. Most of the children under chemotherapy are enrolled in a specific treatment protocol (Neuss et al., 2017). This provides plenty of advantages for the health givers in that it enables them to easily identify, prescribe and avoid medical errors. With proper mechanics to effectively identify these errors, changes in the healthcare systems could help to reduce the medical errors while treatment children aged 3-4 years. It is also important to point out the fact that despite parents of children under outpatient oral chemotherapy could be properly administering the prescribed drugs, the number of required medication and complexity of dosing could be challenging for parents that have not undergone medical training.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Introduction (to the Chapter) and Background (to the Problem) This section describes the overall topic to be investigated, outlines the approach taken for the literature review, and defines the evolution of the problem based on the gap or need defined in the literature from its origination to its current form.
Introduction states the overall purpose of the project.
Introduction provides an orienting paragraph so the reader knows what the literature review will address.
Introduction describes how the chapter will be organized (including the specific sections and subsections).
Introduction describes how the literature was surveyed so the reader can evaluate the thoroughness of the review.
Background provides the historical overview of the problem based on the gap or need defined in the literature and how it originated.
Background discusses how the problem has evolved historically into its current form.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
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Theoretical Foundations

A Complex Systems Theory: This addresses the hierarchical structure and the components within a system (Clancy, Effken & Pesut, 2008). The complex system’s theory will be applied to the children aged 3-4 years and suffering from leukemia and undergoing cancer treatment. The dynamic quality of patients together with the advances in science leading to changes in evidence-based practice, complex adaptive systems can best address the physiologic and psycho-social changes that could be experienced by the patient(Clancy, Effken & Pesut, 2008).Health care providers could adapt the complex systems theory or adaptive system while providing care for children with leukemia. The essential part of oncology care for children with leukemia spans from screening to provision of care. Any individual that transitions across the care continuum are identified as a risk assessment, detection, diagnosis and end- of life care (Mulatish, Dwiprahasto & Sutaryo, 2018). The process of assessing the effectiveness and shortcoming attributed to the provision of care can be challenging. The complex system helps establish effective communication between the patient care and recording of the patient data. Understanding and use of the complex systems theory can help to provide best practices in oncology care coordination and transitions while adapting science drive to improve patient outcomes (Clancy, Effken & Pesut, 2008).

Hope Theory is essential in promotion positive coping while offering treatment for children with leukemia. According to Snyder (1989) hope is a goal-directed thinking where people appraise their capability to produce workable routes to goals. Cancer survivors have shown that hope was positively associated with posttraumatic growth (Yuen, Ho, & Chan, 2014). Hope is related to adjustment, coping and social support for children with leukemia. Hope theory is a useful framework that provides clinicians with interventions for providing psychological adjustments for children with leukemia.

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theoretical Foundations This section identifies the theories or models that provide the foundation for the project. This section should present the theories or models(s) and explain how the problem under investigation relates to the theory or model. The theories or models(s) guide the clinical questions and justify what is being measured (variables) as well as how those variables are related.
This section identifies and describes the theories or models to be used as the foundation for the project.
This section identifies and describes the seminal source for each theory or model.
This section discusses how the clinical question(s) align with the respective theories or models.
This section illustrates how the project fits within other evidence-based on the theory or model.
This section reflects understanding of the theory or model and its relevance to the project.
This section cites references reflecting the foundational, historical, and current literature in the field.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

Review of Literature

Theme-1 Drug Dispensation

According to Mulatish, Dwiprahasto & Sutaryo (2018) the common medical errors when it comes to treatment of patients with leukemia comes in the administration phase of the medication delivery and during the drug-dispensing phase The major types of errors are attributed to the performance deficit, communication, knowledge deficit, errors in the written orders and medication delivery devices (Tumbelaka, Riono, Sastroasmoro, et al., 2014). The pediatric oncology is a high-risk area and could cause plenty of negative health effects if there is incompetence in personnel, management and lack of the supporting infrastructure. It is thus important of all patients receiving chemotherapy to be investigated.

Subtheme: 1 Knowledge Deficit

According to Phillips & Jones, (2014) there are plenty of exceptions that apply to the conversion formulas that are being used to calculate the medicinal dosage for the children. For example, standing orders for ibuprofen or acetaminophen to reduce fever. One has to determine the patient’s weight in kilograms and multiply by the suggested medication in milligrams per kilogram (Saxena et al., 2018). The unfortunate aspect is that errors could result when the clinicians or care giver calculates weights of patients that are over the 40 kg, the threshold at which to consider the adult dosage and standard pediatric dose conversion formula becomes less useful (Hallböök, Lidström & Pauksens, 2016).

Subtheme: 2 Errors in Written Orders and Formula Conversations Deficit

Errors can only be minimized if the clinicians are able to adjust the dosage according to the child’s illness and the overall medical condition which include the presence of diseases that affect the drug metabolism (Phillips, amp & Jones, (2014). For the safety of the children there is need to install systems that performs checks and balances to ensure the safety of children suffering from leukemia. This is identified as not being the case (Phillips, amp & Jones, 2014). In a survey that was conducted, by Hallböök, Lidström & Pauksens (2016), the findings were that about half of all the respondents indicated that pharmacists always recalculates the drug dose before filing an order to allow the issuance of the drugs to the children.

According to Pui et al., (2017) the technological advances which involves the use of the computerized physician order entry together with the decision support bar coding could help to minimize the medical administration errors among children age 3 to 4 years (Philips et al., 2014). The adoption of the clinical decision support software enables the clinicians to effectively reference information on medication and dosing parameters, potential drug interactions and known side effects to reduce the risk of fatalities associated with the medical errors among children. It can further help physicians while doing the order entry and help in determining of therapeutic medication dose based on the weight-based calculation and eliminate the human miscalculations. It further provides warning in instances where the dose could be larger or too small for the intended child reduce the harm that could befall the children’s (Lehmann et al., 2015). 

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According to Weingart et al., (2018) almost all the pediatric medication requires the pediatrician to perform mathematical calculation something that could be complex. The most common calculations involve the use of fractions, percentages and decimals. While conducting the mathematical tests plenty of research have linked nurses to be poor performers in their mathematical skills (Vázquez-Cornejo et al., 2019).The inability to effectively come up with the best computational method and correct therapeutic volume drug dose could be fatal while treating children with leukemia something that has been linked as the major reason for medical errors. In most of the mathematical tests the new interns and nurses were found to possess poor mathematical skills with pharmacist’s poor computational. The research has indicated that the inability to conceptualize the correct mathematical calculation to be performed and the right mathematical process leading to the solution (Leihman et al., 2015). One of the major sources of error come in when a nurse first calculates the does and the volume to be given which is normally based on the concentration that is made available on the stock. Nurses are in many instances made to perform calculations that are needed in order to come up with the right medicine and lack of math skills needed to solve the problem could lead to fatal outcomes.

Most of the nursing staff do not understand how to apply the calculations in the clinical settings (Rivera‐Luna, 2014) Most of the nurses have not been able to use the calculations since school. While the studies involve physicians, nurses need to be able to effectively perform same calculation. In instances where they are unable to do so, they should not administer any medication. Any misplacement of a decimal point could result on dosing error which could lead to overdosing or under dosing among children with leukemia (Mueller, 2014). Some common consequences of such errors for children suffering with leukemia include transient renal failure, tachycardia, respiratory failure and cardiac arrest. Research points out that that dosage calculations for small children are hugely dependent on the use of decimal point in order to get the right results. Further research findings indicate that people that make tenfold calculation errors are more likely to cause other medication errors (Vázquez-Cornejo et al., 2019).

According to Mulatsih et al., (2015) there is a varying incidence of medical errors based on the study method and definition. Various studies have shown that most of the medical errors were found as result of wrong prescription and the incompetence among health workers. According to Mulatsih et al., (2016) nursing understanding of medical safety practice is good and continues to improve upon training and use of better reading and interpretation equipment’s. It further points out that despite having good knowledge on the patient safety, this knowledge is not quite enough when it comes to medical errors. The most common medical errors among leukemia patients between the ages of 3 and 11 years were found to result from the chemotherapy errors. Another error found was the roadmap error that was at 27 percent. Supportive care error is another, as well as timing errors, pharmacy errors and clerical errors were among the least causes of medical errors respectively. The errors that are associated with the roadmaps majorly were linked to the use of outdated, or incorrect roadmap, improper sequence of the therapy phase and the deviations of the drug administration from the one that had been scheduled.

Furthermore, the increased chances of the medical errors result from the use of multiple chemotherapy drug for a single patient. It is thus to use a tool that reflects the medical safety practice as a means to reduce medical errors associated with the treatment of the leukemia among children. The number of medical errors has been found to reduce significantly with health care providers adopting the post-intervention compared to the pre-intervention. With fever being the most common symptom among children receiving chemotherapy. The adoption of the simple medical safety program that are obtained from the findings of the local adverse drug events, people are able to reduce young patients’ harms associated with leukemia care. It is necessary to apply the medical safety practice guideline when ordering, dispensing, and transcribing, administering and the monitoring of young patients with leukemia in order to reduce the patients harm during treatment leading to a long-term outcome in patient safety. The limitation presented by the study conducted by Mulatish, Dwiprahasto & Sutaryo (2018) is that it was majorly based on a limited observation period. This necessitates for a periodical review on the implementation of the monitoring program and that other factors such as infection could contribute to bias that is related to the adverse drug events necessitating for the further investigation of the drug effects. DNP- Direct Practice Improvement (DPI)

Theme 2: Drug Prescription

Research indicates that medication error occurred majorly in nearly 10 percent of the chemotherapeutic agents prescribed that contained all the ambulatory setting. Research indicates that at least one of the errors occurs in 18.8 percent of the children. The further research findings indicated that one-sixth of the parents do not receive chemotherapeutic regimen indicated. Although a huge percentage of errors were found to relate to administration, there were lots of errors that are linked to prescription. Most of the errors in the prescription have been limited to the ones of clinical significance and are in most essence not linked to alter the probability of the survival. The research by Mulatish, Dwiprahasto & Sutaryo (2018) that children that failed to receive corticosteroid could increase the risk for recurrence and the patients with high instance of mercaptopurine despite having a history of previous neutropenia recorded an increased there was a significant increased risk of infection.

According to Khalek et al., (2015) there is little research on the multisite study errors that are associated with medication use for pediatric oncology patients. The research conducted showed that there was a variance on error rates with sites. The inconsistency depicted by the various sites indicates the actual difference in the detection of errors at home visit or medical record review. Millot, et al., (2014) point out the fact that the parent administration errors were mostly due to miscommunications that existed between the parents and clinicians or when it comes to the changing of children’s doses at home. The errors were linked to the fact that the frequent change of doses, caused the bottle labels to be outdated leading to major parental errors. Geng et al., (2015) point out that most of the errors occurred in the nonchemotherapy medication. This was linked to the fact that most of these children perform frequent visits to their oncologist and that they do not need to inquire more about the nonchemotherapy medication use.

Darlin et al., (2018) pointed out that with the error that was detected in their study, multiple support tools will be necessary to support errors that are associated with home medication use for children with cancer. The failure modes and analytical methods have for a long time been relied on to understand the medical error sources of oral chemotherapy use. Akyay et al, (2014) point out that some communication-based errors could be prevented through the adoption of the hospital around hand offs. The pharmacist case-management which involves technology could be adopted in a means to offer support to home medication use. DNP- Direct Practice Improvement (DPI)

Subtheme1: Errors Associated with Wrong Prescription

According to Geng et al., (2015). The medication errors that are associated with pediatric patients between the ages of the 3 and years presents plenty of paucity of data and thus difficult to place the results of the study in the proper contexts. The huge percentage of errors found in this scale are associated with the prescribing errors. Most common errors for children are associated with missing date, this is in addition to the huge percentage of errors that occur during the prescribing stage. The report indicates high rates, which will be much higher in pediatric patients with most of them accounting to 14 of the potential errors that were reported. Moreover, the analysis of comparing the dose versus the weight for selected medication showed that the rate of true errors among the drugs and the patients were much lower (Geng et al., 2015).

According to Mulatish, Dwiprahasto & Sutaryo (2018) medical safety practice is a safe procedure in the medication process. They point out that it is critical to investigate the medical safety practices among cancer children patients considering that they were found to the high risk. There are over 250,000 childhood cancer incidents annually with the highest incidences coming from developing countries. Most of the medical errors for cancer patients were found to be common among patients from developing countries and attributed to the lack of proper facilities and the nursing staff to effectively handle the patients. DNP- Direct Practice Improvement (DPI)

According to Schwappach, Pfeiffer, Taxis (2016) there has been improvement of pediatric management of cancer patients upon the improvement of technology equipment used to treat patients. Meanwhile, there has been increased mortality rates for children aged 3 to 11 years with research linked the increased rates to treatment toxicity. Other studies have also shown that the increased incidences of errors are linked to complex combinations and the chemotherapy. According to (Schwappach, Pfeiffer, Taxis (2016) that there is the need to understand the processes of the administration of chemotherapy to reduce the incidence of medical errors and risks that are attributed to the process. DNP- Direct Practice Improvement (DPI)

Subtheme 2: Errors Associated with Medical Fillings

According to (Schwappach, Pfeiffer, Taxis (2016) when it comes to chemotherapy transcribing aspects, various studies have shown that there have been a rise in the post-intervention especially in items such as height measures, body mass index, documenting of history of allergy, psychosocial status and chemotherapy planning. Research further indicates that a few aspects such as documenting of the chemotherapy regiment and planning did not meet 100 percent planning. It is key to point out that out of the 49 percent of the drugs ordering stage, 11 percent are done during transcription which is normally inclusive of the frequency, routes or times of deviation being included. There are some aspects of chemotherapy administering that have met 100 percent of the criteria for intervention for patients with leukemia. The post-intervention had the patient’s identity, drug name, drug dose, route of administration and the calculated dose. The study was in line with the previously conducted study which stated that approaching and institution by adopting a multi-discipline system helps to reduce medication errors while the conducting chemotherapy. It also was found that adherence to the drug labeled filings helped in increasing post intervention. DNP- Direct Practice Improvement (DPI)

According to Mulatish, Dwiprahasto & Sutaryo (2018) found that chemotherapy preparation by two different health workers that was independently carried out did not conform to the 100 percent standard something they attributed to the inadequate number of nurses compared to the number of patient that resulted in the lack of double checking of chemotherapy drugs. The study further found out that double checking of chemotherapy drugs that has two different independent nurses is a common thing and is believed to significantly reduce medication error among the leukemia and other cancer patients (Schwappach et al., 2016). Other research have also documented that drug verification among the nurses have over time reduced increasing the chances of medical errors among children. Most of the nurses fail to verify the drugs to check for the expiry dates and hence making the drug administration erroneous. It is key to avoid the medical error aspect considering that this medical error is common among 3 percent of medical errors for any patient regardless of age. DNP- Direct Practice Improvement (DPI)

The study by Mulatish, Dwiprahasto & Sutaryo (2018) found that chemotherapy monitoring had gotten better of post-intervention compared to pre-intervention. This is of great significance for children that are being administered with more than one drug and are less than five years of aged. These cohorts are majorly prone to chemotherapy medication error while administering. It is key to point out the fact that there is a huge difference when it comes to the documentation and assessment of patients suffering from leukemia. Further research has documented that 94 percent of medical errors that has a low harm potential and the sixty percent of the near-miss medication errors normally occur in the prescribing process. Kaush et al., 2010) points out that the most common cause of the medication errors during prescription normally occur in inappropriate abbreviations, dosing error and legality aspect. DNP- Direct Practice Improvement (DPI).

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Theme 3: Parental Administration and Nurse Administration

Subtheme1: Parental Education on Drug Administration

According to Mulatish, Dwiprahasto & Sutaryo (2018) the process of the getting consent and family education is essential to increase post-intervention. In the study one aspect that was found not to escalate in post-intervention compared to the pre-intervention was family being given emergency number to be selected for chemotherapy drugs. This was majorly due to the unavailability of the emergency number on the informed consent form and form of family education related to the illness. The process of getting a consent after the provision of clear information given after provision of enough education is important in that communication is essential in the lowering of the medication errors (Schwappach, Pfeiffer & Taxis, 2016). DNP- Direct Practice Improvement (DPI)

According to Walsh et al., (2013) with the improvement of the medical care, most of the Americans are taking more of the medications at the homes than ever before. The number of the children that are taking their medication at home have increased in major drug classes. The major reasons for the rising trends in the home consumptions were attributed to the increasing use of the oral agents to treat patients with cancer, rise in the number of cancer survival rates, the rise in the number of children that are in need of ambulatory care and improvement in survival rates for children with the congenital anomalies. There is little research on the error rates that is present in the outpatient setting as a result of medications being administered by patients and their families (Walsh et al., 2013).

There is little research on the outpatient medical consumption at home. It is for this reason that there is little information or understanding on the manner in which medicines are used at home. Most of the studies have majorly relied on retrospective and large databases as a means to reduce the casualty and the risk factors. The medical records review only provide errors that were documented only on record. In studies it only relies on the errors that are reported by parents (Geng et al., 2015). Various research has pointed out this independence on parents’ error reports could at times be erroneous and thus cannot be relied upon. In other studies parents are asked to demonstrate proper dosing of home medication while being at the clinic. Some studies have pointed that the demonstrations that are being provided while at the facility are part of the entire process of home medication use and could be subjected to sampling bias. These studies point out that there is the need to investigate the spectrum errors associated with home medication use and also access the frequency, severity and target education as a means to come up with the most appropriate interventions to the problem (Khalek et al., 2015).

According to Oberoi, Trehan & Marwaha, (2014) the children that children aged between 3 and 4 years are at high risk of experiencing home medication errors. Research indicates that about 10 percent of the missed cancer doses are normally reported to have occurred from home which is a dangerous thing. Underdosing of cancer patients could lead to the fatal results. Walsh et al., (2013) conducted research to determine the types of medical errors that occur at homes for children with cancer. The study performed prospective study from which it was conducted in 3 sites which involved the reviewing of the medical records and bottle labels, and direct observed medication at home. The findings of the research showed that the medication errors for the children of the ages 3 and 4 with almost one in every two parents having been exposed to a medical error while offering treatment at home. In most of these errors the medical administration errors accounted for most of medical errors at home. The type of administration error where the parents administer the wrong dose or medication to the children. The injury rate that is associated to this error was high with the study showing that 4 parents out of the 100 experience high injuries as a result of wrong dose administration. DNP- Direct Practice Improvement (DPI)

According to Pui et al, (2018) in all the ways that the patients can be harmed during treatment, medication errors are identified as being the most common means and the most easily preventable. In instances where medication errors occur, the patients are at high risk of death than adults (Saxena et al., 2018). Evidence show that most of the medication errors do harm adult patient. There are over 100 undetected errors. The over 100 medication errors that were not detected are normally as a result of adverse drug event that normally leads to harm or death of the patient. Considering the number of inpatient medication orders that are written on daily basis, there is a high number of the pediatric medication errors that are likely to be staggering (Sheik et al., 2014).

With the current emergence of the research results, there is a great understanding of the impact of medical error on children. Several researchers have found that there are around 4 to 7 per 100 medication orders for children suffering with leukemia. Schmidt, (2019) point out that pediatric outpatients had three times the risk of developing the adverse drug reaction when compared to the adult outpatients. The risk is particularly high if in instances where the medication was used for an off-label indication something that is common among the pediatrics. Despite the study finding plenty of significant errors rates, further findings from other research indicates the frequency of pediatric medication errors from ambulatory settings are much greater. This is attributed to the fewer checks and balances that were put in place as means of preventing these errors.

Subtheme 2: Error from Ambulatory Setting Associated with Lack of Knowledge

According to Sulis et al., (2018) there is need to conduct further research for patient safety in the ambulatory care setting. This has been promoted by the lack of proper policy considering the unique vulnerabilities present in ambulatory settings that exposes the children to the risk death and harm from medical errors (Taverna et al., 2017). The risks to harm were attributed to the glaring lack of knowledge and reliance on ambulatory care something that is not present in the inpatient care (Taverna et al., 2016). Medication errors come in different forms, but they all do not result in the injury or death (Taylor et al., 2016). The medication errors could be defined as being preventable, and the improper use of eh medication could occur during any stage of administering the medication which include the ordering, dispensing, and monitoring. The adverse drug events could occur at any stage of the drug administration. DNP- Direct Practice Improvement (DPI)

According to Tremolada et al., (2015) there are different phases of care where medication errors are likely to be experienced in children. In pediatrics, the most common stage where problems could occur is the prescribing or ordering phase which is normally characterized by errors that come with dosing and the administering phase (Tremolada et al., 2016). Taylor et al., (2016) point out that when respondents to patient safety survey to identify the profession that is responsible for the patient safety a huge percentage of the individuals assigned the responsibility to nurses regardless of the factors that contributed to the error. It is thus the role of the nurse that are involved in delivery of care to ensure that they are well-informed on the care or patients and the medications they order.

According to Wang et al., (2017), nurses do play a significant role in the administration of the various medication when it comes to pediatric medication errors. The research points out the fact that despite most errors occur before administration of the drug, the medical errors that are not caught or intercepted by the nurses could be fatal for children living with leukemia (Zannini et al., 2014). The fact that nurses are the one that predominantly administer medications to patients, they are always the last barrier that is present between the mediation errors and the serious harm (Yeh et al., 2014). Nurses are the ones tasked with the responsibility of ensuring that young patients have received the right medication and the most appropriate time. They also have the responsibility of monitoring patients they were assigned to observe the adverse effects of the medication early in time to prevent injury or harm (Whitlow et al., 2015). DNP- Direct Practice Improvement (DPI)

The children aged 3 and 4 years are at greater risk of being victims of the medication errors. The medical errors could be fatal considering that they do not have an immature physiology and developmental limitations that can enable them to effectively communicate or self-administer medications as it relates to adults (Schwappach, Pfeiffer, Taxis et al., 2016). Another factor for being victims of medical errors is that most of the formulations for treating Leukemia are meant for adults. It thus means that in most of the instance’s pediatric indications and the dosage guidelines are not always contained in the medication (Mulatsih, Dwiprahasto & Sutaryo, 2018). The drugs are majorly in the form of formulations that are normally weight-based. This means that in order for any drug to be used by children, there is the issuance of safe dosages which are normally fractions of adult-based drugs which must also be calculated (Zang et al., 2014). DNP- Direct Practice Improvement (DPI)

According to Mulatsih, Dwiprahasto & Sutaryo, (2018) the process of determining the pediatric dosages is complex. The complexity is mostly because one uses the child weight. The children that take these types of medications are at high risk of being involved in the medication errors compared to the children that take medication that do not required any calculations. In instances of reduced calculations, the risk is decreased significantly (Wang et al., 2017). The risk is much higher if the children are in ICUs, the ones that are in EDs and if seriously ill between the 4 am and 8 am hours or the weekends, children whose weight have not been documented and the ones that are receiving IV medication.

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Review of the Literature This section provides a broad, balanced overview of the existing literature related to the project topic. It identifies themes, trends, and conflicts in methodology, design, and findings. It describes the literature in related topic areas and its relevance to the project topic. It provides an overall analysis of the existing literature examining the contributions of this literature to the field, identifying the conflicts, and relating the themes and results to the project. Citations are provided for all ideas, concepts, and perspectives. The investigator’s personal opinions or perspectives are not included.
Chapter 2 needs to be at least 20-25 pages in length. It needs to include a minimum of 50 scholarly sources with 85% from the sources published within the past 5 years. Additional sources do not necessarily need to be from the past 5 years. It should not include any personal perspectives.
This section describes each variable in the project discussing the prior evidence that has been done on the variable.
This section Discusses the various methodologies and designs that have been used to understand evidence presented on topics related to the project. Uses this information to justify the design.
This section argues the appropriateness of the practice improvement project’s instruments, measures, and/or approaches used to collect data.
This section discusses topics related to the practice improvement project topic and may include (a) studies relating the variables (quantitative) or exploring related phenomena (qualitative), (b) evidence –based studies on related factors associated with the topic, (c) Relates the literature back to the DPI-project topic and the practice problem. d) studies on the instruments used to collect data, and (e) studies on the broad population for the project. Set of topics discussed in the Review of Literature demonstrates a comprehensive understanding of the broad area in which the topic exists.
Each section within the Review of Literature includes an introductory paragraph that explains why the particular topic was explored relative to the practice improvement project topic.
Each section within the Review of Literature requires a summary paragraph that (a) compares and contrasts alternative perspectives on the topic, (b) provides a summary of the themes relative to the topic discussed that emerged from the literature, and (c) identifies how themes are relevant to your practice improvement project topic.
The types of references that may be used in the literature review include empirical articles, a limited number of practice improvement projects, peer-reviewed or scholarly journal articles, and books that present cutting-edge views on a topic, evidence-based, or seminal works.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

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Summary

There are of the practical steps that nurses can undertake in order to improve pediatric medication safer for patients with leukemia (Inaba et al., 2017). While many of the things would begin in a good way to start. Understanding of the near misses is the key to managing medication errors (Cooper & Brown, 2015). Various research has indicated that the total number of the reported medical errors are few and it is difficult to determine these medical errors in its actual sense. The situation is even worse for the children aged between 3 and 4 years. Furthermore, there are various underreport that if they fear reprisal or if they are uncertain of the definition of error. It is the role of the managers to ensure that the nurses among other health providers are not punished for the mistakes, that error is encouraged with the hiding mistakes is discouraged. DNP- Direct Practice Improvement (DPI)

The lack of knowledge on the kind of medication and how to administer it has been linked by several studies as the major reason for the rise in the medical errors. To effectively manage leukemia among the children aged 3 and 4, it is key for the nurses and the caregivers to have knowledge of the medication that is being administered for the child (Hunger & Mullighan, 2015). They need to understand the medication that is being used, whether the medication is appropriate for the child, the recommended therapeutic dosage range and how these patients could respond if there were adverse reactions (American Society of Hospital Pharmacists, 2018) In any instance where one is not concerned on the dosage, it is key to ask questions as a means to gain more insights to the patient’s interests (Reinhardt et al., 2019). The lack of information or knowledge on drugs being administered has been found to contribute to fifteen percent of medication administration errors among nurses that need to take advantage of pharmacists knowledge when in to preparing, administering and monitoring drug therapy (Hinojosa‐Amaya et al., 2016). DNP- Direct Practice Improvement (DPI)

In instances of medication is prescribed for an off-label use in a child, It important to check the suggested dosage and duration of treatment with a pharmacist, in areas where there appropriate references with the current edition of physician desk reference in a computerized drug order entry system. In instances where medication is prescribed in an off-label use, it could be difficult to find the correct dose (Maaskant et al. 2015). With the improvement of knowledge of the medication and plenty of medication increases, nurses continue to improve their knowledge on means to ensure medication errors. There is need to establish higher medication errors and nurses should be cautious when administering them and double-check any orders (Tuckuviene et al. 2016). DNP- Direct Practice Improvement (DPI)

Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
Summary This section restates what was written in Chapter 2 and provides supporting citations for key points. It synthesizes the information from the chapter using it to define the “gaps” in or “evidence –based practice needs” from the literature, the theories or models to provide the foundation for the project, the problem statement, the primary clinical question, the methodology, the design, the variables or phenomena, the data collection instruments or sources, and population. It then provides a transition discussion to Chapter 3.
This section synthesizes the information from all of the prior sections in the Review of Literature and uses it to define the key strategic points for the project. This section summarizes the gaps and needs in the background and introduction and describes how it informs the problem statement. This section identifies the theories or models and describes how they inform the clinical questions. This section uses the literature to justify the design, variables or phenomena, data collection instruments or sources, and answer the clinical questions on your selected intervention protocol, clinical setting and patient population.be evaluated.
This section builds a case for the project in terms of the value of the project.
This section explains how the current theories, models, and topics related to the DPI project will be advanced through your intervention and outcomes.
This section summarizes key points in Chapter 2 and transition into Chapter 3.
This section is written in a way that is well structured, has a logical flow, and uses correct paragraph structure, sentence structure, punctuation, and APA format.
NOTE: Once the document has been approved by your chairperson and your committee and is ready to submit for AQR review, please remove all of these assessment tables from this document. Score 0 (not present); 1 (unacceptable; needs substantial edits); 2 (present but needs some editing); 3 (publication ready).

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Criterion	Learner Score (0, 1, 2, or 3)	Chairperson Score (0, 1, 2, or 3)	Comments or Feedback
References
This section provides a minimum of 50 references with minimum of 85% of the 50 references published within the last 5 years. Additional references do not have to be published within the past 5 years.
Range of references includes founding theorists, peer-reviewed articles, books, and journals (approximately 90%).
Reference list is formatted according to APA (6th ed.).For every reference there is an in-text citation. For every in-text citation there is a reference.
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