An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference.

BACKGROUND: Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered. OBJECTIVE: To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference. METHODS: We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016-May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported. RESULTS: During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3-48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57-100.0]) and glucagon (3/4 or 75% [95% CI 32.57-100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04-91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47-76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36-60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19-67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19-67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64-36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31-5.98]). CONCLUSIONS: Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.

Quality Evaluation of a Checklist for Intubation Preparation in Graduate Medical Education.

Background Rapid sequence intubation (RSI) is a multistep process that emergency physicians commonly perform. Unfortunately, there is little published in the graduate medical education literature regarding the use of checklists for RSI education. Methods We developed a pre-intubation checklist for RSI preparation and evaluated emergency medicine residents' use of it. We developed the checklist using a three-round modified Delphi process among a group of emergency medicine faculty physicians within our institution. Over a three-year period, residents were randomized into two groups: a "checklist group" and a "without-checklist group." Residents were then evaluated for RSI critical step completion in a simulated critically ill patient by two independent study investigators. Inter-rater reliability kappa scores were calculated. Following completion of the scenario, residents in both groups were asked to complete an anonymous survey. Both groups had access to the checklist at the time of the survey. The survey was used to determine if they found the checklist helpful. Odds ratios with p-values, at an alpha of 0.05 for significance, were computed for checklist items comparing the checklist and without-checklist groups. Data analysis was performed using SAS software (SAS, Cary, NC v 9.4). This study was approved by the authors' Institutional Review Board. Results Each assessment was completed by two investigators. Inter-rater reliability was substantial (κ=0.79). Residents having access to the checklist were more likely to verbalize a critical step with a p-value of < 0.0001 and an odds ratio of 2.17 (95% CI: 1.48, 3.19). The checklist group normalized vital signs prior to intubation in 25/28 (89%, 95% CI: 72.81, 96.29) versus only 6/29 (21%, 95% CI: 9.85, 38.39) with a p-value of <0.0001 in the without-checklist group. The checklist group evaluated for difficult laryngoscopy 26/28 (93%, 95% CI: 77.36, 98.02) versus only 21/29 (72%, CI 95% 54.28, 85.30) with p=0.0223 in the without-checklist group. All of the surveyed residents indicated that the checklist would be helpful for future use in the ED. Conclusion This RSI checklist improved adherence to preparatory steps of RSI. Utilizing a checklist increased evaluation for a difficult airway and normalizing vital signs. Residents found the checklist helpful for ED use.

Methods Used to Obtain Pediatric Patient Weights, Their Accuracy and Associated Drug Dosing Errors in 142 Simulated Prehospital Pediatric Patient Encounters.

Background: Prehospital pediatric drug dosing errors occur at a high rate. Multiple factors contribute to these errors. The contribution of weight estimation errors to drug dosing errors is unknown. We describe methods used to obtain weights and resulting drug dosing errors. Methods: As part of a quality improvement study in 16 EMS agencies, we conducted four simulated pediatric scenarios: seizing, hypoglycemic infant, infant cardiac arrest, 18-month old burn and a 5-year old with anaphylactic shock. Crews used their regular drug bags and equipment. Simulations were observed by study team members with video review and scored on a standardized scoring sheet. Results: 142 scenarios were completed. Methods to obtain patient weights were: asking parent 17/142 (12.0%), patient age 35/142 (24.8%) and Broselow-Luten Tape (BLT) 89/142 (63.1%). There were 19 (13.4% 95% CI 8.5, 20.0) incorrect weight estimations resulting in 18 (12.7% 95% CI 8.2, 19.2) dosing errors (1 asking parent, 9 patient age and 8 BLT). Ten dosing errors were directly caused by weight estimation errors. In 41/89 (46.1% 95%CI 36.1, 56.4) BLT uses there was a near-miss error that did not result in a dosing error. One pound to kilogram conversion error occurred. Conclusions: BLT is the most frequently used method to obtain a patient weight. Drug dosing errors were most frequent with patient age, followed by BLT and asking the parent. System-based solutions-weight determination hierarchy, not using the BLT on seated patients, and more frequent training and practice with the BLT-are needed to improve drug-dosing accuracy.

Dosing Errors Made by Paramedics During Pediatric Patient Simulations After Implementation of a State-Wide Pediatric Drug Dosing Reference.

Background: Drug dosing errors occur at a high rate for prehospital pediatric patients. To reduce errors, Michigan implemented a state-wide 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 stopcock, and dilution of certain drugs to different concentrations.Purpose: To evaluate the rate of medication errors, including errors of omission and commission, after implementation of a state-wide PDR.Methods: EMS crews from 15 agencies completed 4 validated, simulation scenarios: an infant seizing, an infant cardiac arrest, an 18-month-old with a burn, and 5-year-old with anaphylactic shock. Agencies were private, public, not-for-profit, for-profit, urban, rural, fire-based, and third service. EMS crews used their regular equipment 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. An error was defined as [Formula: see text]20% difference compared to the weight-appropriate dose. Descriptive statistics were utilized.Results: A total of 142 simulations were completed. The majority of crews were (58.3%) Emergency Medical Technician-Paramedic (EMTP)/EMTP. For the cardiac arrest scenario, 51/70 (72.9%; 95% CI: 60.9%, 82.8%) epinephrine doses were correct. There were 6 (8.6%, 95% CI: 2.0%, 15.1%) 10-fold overdoses and one (1.4%; 95% CI: -1.4%, 4.2%), 10-fold under dose. In the seizure scenario, 28/50 (56.0%; 95% CI: 42.2%, 69.8%) benzodiazepine doses were correct; 6/18 (33.3%; 95% CI: 11.5%, 55.1%) drug dilutions were incorrect resulting in dosing errors. Unrecognized air was frequently entrained into the administration syringe resulting in under doses. Overall, 31.2% (95% CI: 25.5%, 36.6%) of drug doses were incorrect. Obtaining an incorrect weight led to a drug dosing error in 18/142 (12.7%, 95% CI: 7.2%, 18.2%) cases. Errors of omission included failure to check blood sugar in the seizure scenario and failure to administer epinephrine and a fluid bolus in anaphylactic shock.Conclusion: Despite implementation of a PDR, dosing errors, including 10-fold errors, still occur at a high rate. Errors occur with dilution and length-based tape use. Further error reduction strategies, beyond a PDR and that target errors of omission, are needed for pediatric prehospital drug administration.

Air Medical Curricula in Emergency Medicine Residencies: A National Survey.

OBJECTIVE: The aim of this study was to determine if a common air medical curriculum exists among Accreditation Council for Graduate Medical Education (ACGME) emergency medicine (EM) residencies. METHODS: Institutional review board exemption was obtained. A cross-sectional survey study design was used. All ACGME-approved EM residencies as of February 2013 were identified, and the program directors were e-mailed a 3-question survey. Descriptive statistics were calculated for each response, and a response bias analysis was completed. RESULTS: All 160 ACGME EM residencies were contacted by e-mail. One hundred six (66%) programs responded. Sixty-nine (65%) of the respondents offered an air medical experience. Only 25 of the 69 (36%) stated that they had a formal air medical curriculum, and 15 programs provided a copy of their curriculum. Protocol education was present in 80% of programs. Safety training was present in 60% of the programs. Financial education was present in 7% of programs. There was no statistically significant difference between responders and nonresponders except for residency class size. CONCLUSION: After 30 years of published articles and position statements calling for standardized air medical resident crew member training, there is still no standardized training program among emergency medicine residencies.

Successful airtraq use in an air medical transport system.

INTRODUCTION: There is a large body of literature that shows that the AirTraq device achieves equal or superior rates of successful intubation in all classes of user. A recent prospective human trial of the device questioned the first pass success rate and whether effective training could occur outside the Operating Room (OR). The purpose of this study was to investigate the first pass success rate for intubation with the AirTraq (AT) device utilizing only mannequin training in an air ambulance setting from Aug. 1 2009 to Aug. 1 2012 and compare it to direct laryngoscopy (DL). HYPOTHESIS: We hypothesize that the AirTraq device will be as effective overall as direct laryngoscopy, and that this requires no OR training to achieve. METHODS: A retrospective chart review of 161 intubations by air ambulance flight nurses from Aug. 1, 2009 to Aug. 1, 2012 was conducted. Data regarding date of service, devices used, number of attempts, rescue device use, and complications was gathered and analyzed. The generalized estimating equation and the chi-squared test were used to evaluate the data. RESULTS: 161 intubations were reviewed. 135 met inclusion criteria. Overall first pass success rate for AT was 82% (68/83) and DL was 74% (35/47). Overall first use success rate for AT was 79% (71/90) and DL was 70% (43/61). The overall success rate of intubation for any patient in which either AT or DL was attempted is 96% (130/135). CONCLUSION: AirTraq was shown to be as effective as direct laryngoscopy. All air crew training for the AirTraq device was performed on mannequins. The successof the device compared to DL shows that mannequin training is sufficient to implement the AirTraq device for pre-hospital intubation.