ANALYSIS OF DOSING ERRORS MADE BY PARAMEDICS DURING SIMULATED PEDIATRIC PATIENT SCENARIOS AFTER IMPLEMENTATION OF STATE-WIDE PEDIATRIC DRUG DOSING REFERENCE
BACKGROUND: Medication errors occur at a high rate for prehospital pediatric patients. Epinephrine dose errors have been ³ 60%. To reduce errors, Michigan implemented a pediatric dosing reference (PDR), with doses listed in milliliters, the requirement that doses be drawn into a smaller syringe from a pre-loaded syringe using a stop cock and dilution of drugs to standard concentrations.
PURPOSE: To evaluate the prevalence of medication errors by paramedics treating pediatric patients after the implementation of a state-wide PDR.
METHODS: 8 EMS agencies completed 2 validated, pediatric scenarios: infant seizing and infant cardiac arrest. Agencies were private, public, not for profit, for profit, urban, rural, fire-based and third service. Simulations took place in a simulation center or mobile simulation unit. EMS crews used their regular equipment with sham drugs and were required to carry out all the steps to administer a drug dose. Two evaluators scored crew performance via direct observation and video review. A dose error was defined as >= 20% difference compared to the weight-appropriate dose. Descriptive statistics were utilized.
RESULTS: 80 simulations have been completed and initial analysis has been conducted using descriptive statistics. The majority of crews were EMTP/EMTP. In cardiac arrest scenarios, 8/20 (40%; 95% CI 18.5%, 61.5%) epinephrine doses were incorrect. In 0/20 doses, there was no cross check of the drug volume prior to administration. There were 6, ten-fold overdoses and one, ten-fold underdose. In seizure scenarios, 5/11(45%; 95% CI 16%, 74.9%) benzodiazepine doses were incorrect (2 underdoses, 3 overdoses). 2/9 (22%; 95% CI 0%, 49.4%) drug dilutions were incorrect resulting in large dosing errors. In 1/10 cases (10%; 95% CI 0%, 28.6%) the crew was unable to dilute D50 to D25. Unrecognized air bubbles were frequently entrained in the administration syringe resulting in underdoses. In 11/20 (55%) of cases there was an error using the length-based tape for weight determination
CONCLUSION: Epinephrine dose errors have decreased since implementation of PDR, but frequent ten-fold errors still occur. Cross checks of drug doses do not occur. Errors occur with dilution and length-based tape use. Error reduction strategies are needed for pediatric prehospital drug administration.
DENOMINATOR: 13 sims per case
Adrenalin vs adenosine
Little closed loop and no cross check
Error of omission (checking bld glc, not giving epi for anaphylaxis )
Error of commission (repeat doses of midaz)
Faulty use of the BLT (not pulling child out straight or not measuring in sections)
Using BLT for doses, confusion whether to use BLT or cards
Errors with dilution (too much too little)