At BD, patient safety is the north star of our work to advance the world of health. As we recognize World Patient Safety Day and reflect on this year’s theme of ensuring safe care for every newborn and child, it’s an opportunity to highlight advances in medication management technology that are particularly impactful for some of our most vulernable patients: babies and children.

We especially want to emphasize the WHO call to action of providing individualized care for every child. Studies estimate that 14-31% of pediatric patients are affected by medication errors, with dosage and administration errors being the most common types¹. To help mitigate the high rate of errors, the Institute for Safe Medication Practices (ISMP) released updated (2022) Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology, emphasizing the importance of incorporating technology into intravenous (IV) compounding processes².

IV compounding is a highly precise process of preparing sterile medications to be administered directly into a patient's vein through an intravenous line and typically include chemotherapy, electrolyte and fluid replacement, antibiotics, and sedatives and anesthetics. Historically, compounding was manual, but over the past few decades, technology has been adopted in healthcare worldwide, including gravimetric compounding, which improves the accuracy of IV medication preparation by weighing the actual product against the expected weight. This technology identifies significantly more errors compared to volumetric methods with error capture rates up to 100 times higher than traditional compounding methods, which contributes to a lower incidence of preventable medication errors³. This is especially important for our pediatric and neonatal patients; due to their size, a small dosing error in these patients could be detrimental.

However, despite offering enhanced safety and dose accuracy, adoption of gravimetric compounding remains low, with the technology in use at just 7.7% of all US hospitals, due to barriers including financial and labor resource constraints and rigorous training requirements for pharmacy technicians, all of which may initially increase preparation time⁴.  

Envisioning a Future Without Preventable Errors

The consequences of medication compounding preparation errors can be profound. Patient safety advocate Christopher Jerry’s two-year-old daughter, Emily, tragically passed away as the result of a preventable compounding error during chemotherapy treatment. Following this event, Jerry established the Emily Jerry Foundation and has since dedicated his life to raising awareness about preventable medical errors and advancing safe medication practices across health care. In his lectures and keynote presentations, Jerry has consistently underscored that proven technologies to help prevent such tragedies were already available at the time of Emily’s death.

For example, barcode medication verification technology—first introduced in 1974 and widely utilized in retail industries—had not yet been adopted in the hospital pharmacy where Emily was treated. Had it been in place, the scanning of the vial of hypertonic saline, a high-alert medication, would have immediately triggered alerts to both the pharmacy technician and supervising pharmacist, thereby preventing the error and saving Emily’s life. This experience has informed Jerry’s unwavering advocacy for ensuring that clinically validated technologies are not viewed as optional enhancements, but rather established as the standard of care across health systems.

A Call to Action: Elevating Patient Safety with Proven Technologies

This past year, BD held a compounding summit to discuss opportunities to help address adoption challenges and safety concerns. We sponsored a group of compounding experts to review the risks of compounding and the benefits of technology in improving the overall compounding process.

We recently published new insights in the American Journal of Health-System Pharmacy (AJHP) to support hospitals and health systems considering the adoption of gravimetric IV compounding workflow technology. The article offers insights and guiding principles informed by the experience and expertise of eleven health system subject matter experts, including pharmacy leaders who have successfully implemented gravimetric compounding workflow technology. As IV compounding technology advances, our hope is that these guiding principles give pharmacy leaders greater confidence in adopting gravimetric compounding.

We strongly urge hospitals and health systems to adopt a proactive, risk-based strategy for incorporating gravimetric analysis and other critical safety checks into their compounding workflows. This approach is critical to improving dose precision, minimizing errors, and safeguarding pediatric patient health.