A Mixed Methods Investigation of Pediatric Medication Administration Dosing Errors in Emergency Medical Services

Date of Award


Degree Name

Doctor of Philosophy


Interdisciplinary Health Sciences

First Advisor

Kieran Fogarty, Ph.D.

Second Advisor

John Hoyle, Jr., M.D.

Third Advisor

William Rantz, Ph.D.


Emergency medical services, medication errors, patient safety, pediatrics, prehospital, root cause analysis


Emergency Medical Service (EMS) clinicians work in unideal environments where complex lifesaving treatment occurs. Medical errors occur at high rates, and research supports that care provided to children has higher rates of error. One area of concern is pediatric medication administration dosing errors. These errors occur at a rate of 31%, meaning that nearly a third of all children receiving medication in this environment are administered the wrong dose. Unfortunately, previous strategies have failed to reduce incidents of error below 31%. This may be because little is known about the causes of these errors. This study used a mixed-methods, simulation-based approach to examine pediatric medication administration and identify the root causes of error.

A total of 11 EMS crews from two agencies in Michigan were recruited. Each crew engaged in three simulated pediatric emergencies. Two doses of epinephrine, midazolam, or fentanyl were indicated in each simulation. Crew performance was video recorded, and the research team directly observed and measured the doses administered. After the simulations were complete, each crew participated in post-simulation interviews to further investigate the crew’s performance, decision-making, and causes of error. A multidisciplinary research team analyzed data from these simulations and other supporting information through a modified Delphi method and brainstorming sessions to identify the active and latent errors leading to medication dosing errors. Deductive thematic analysis was used to analyze interview transcripts, and basic descriptive statistics were used to examine the frequency and magnitude of errors.

A total of 19 medication dosing errors were observed out of the 66 administrations, resulting in a 28.8% (CI: 41.3%, 18.3%) error rate. Active errors were categorized as slips (n= 13, 68.4%), lapses (n= 0, 0%), and mistakes (n= 6, 31.6%). Immediate causes of active errors were identified, including unrecognized air in the syringe (n= 6, 31.6%), incorrect weight (n= 4, 21.0%), communication issues (n= 6, 31.6%), and other immediate causes (n= 3, 15.8%). Numerous latent errors leading to active errors were identified throughout the EMS system. These included issues with EMS protocols, limited training and development, poor design of cognitive aids, the paramedic workforce shortage, medical device issues, and task complexity. The research team recommended improvements and standardization of PMA equipment, improvements to cognitive aids, implementation of assistive technology, improvements to protocols, increased frequency and quality of training, and increased research on PMA dosing errors.

These data offer detailed insight into the failures within the EMS system that lead to pediatric medication dosing errors. Strategies aimed to reduce the frequency of these errors must be designed to address these failures, or this issue will continue to persist. Any strategy that aims to address this issue should be examined for efficacy prior to implementation in EMS.

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