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Plan Ahead – Minimizing the Risk of Pediatric Medication Errors Implications for Disaster Medicine . William Fales, MD, FACEP Michigan State University Kalamazoo Center for Medical Studies 5 th District Medical Response Coalition Kalamazoo County Medical Control Authority. Acknowledgment.

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plan ahead minimizing the risk of pediatric medication errors implications for disaster medicine

Plan Ahead – Minimizing the Risk of Pediatric Medication ErrorsImplications for Disaster Medicine

William Fales, MD, FACEP

Michigan State University Kalamazoo Center for Medical Studies

5th District Medical Response Coalition

Kalamazoo County Medical Control Authority

acknowledgment
Acknowledgment

Funding for the MI PEEDS Study was provided by the:

US Department of Health and Human Services

Health Resources and Services Administration

Bureau of Maternal and Child Health

EMS for Children Program

disclosures
Disclosures

Nothing to Disclose

fortunately
Fortunately

Mass Casualty Incidents

Involving Children Are

Relatively Uncommon

also fortunately
Also, Fortunately

Isolated Incidents Involving

Critically Ill and Injured

Infants and Children

Are Relatively Uncommon

fundamental disaster medicine concepts
Fundamental Disaster Medicine Concepts
  • Effective response to an MCI involves application of basic and advanced skills and critical clinical decision making with limited resources.
  • Being able to respond to day-to-day incidents improves (but does not guarantee) your ability to respond to the “big ones”.
  • Corollary: If you can’t handle the “little ones” effectively, you sure won’t be able to handle the “big ones”.

So How Well Do We

Handle the “Little Ones”?

medication challenges in ems a tail of 4 michigan studies
Medication Challenges in EMS(A Tail of 4 Michigan Studies)
  • Hoyle Study: EMS Med Dosing Errors in Peds
  • Lammers Study: Root Cause Analysis of Errors in Simulated Peds Emergency
  • Michigan EMS Information System Peds Seizure Study
  • RAMPART Study
med dosing errors in peds treated by ems
Med Dosing Errors in Peds Treated by EMS
  • Prehospital Emergency Care
    • Hoyle, et al
    • January/March 2012
  • Retrospective review of MERMaID Records
    • Jan 1, 2004 to March 31, 2006
  • Correct Dose = +/- 20% of protocol dose
weight vs age
Weight vs. Age

95th %ile

50th %ile

5th %ile

conclusion
Conclusion

Medications delivered to children in the prehospital setting by paramedics were frequently administered at doses outside of the proper range when compared with documented patient weights. EMS systems should develop strategies to reduce pediatric medication dosing errors.

mi peeds study
MI PEEDS Study
  • MI Pediatric Excellence and Error Detection with Simulation Study
    • EMS-C Targeted Issues Grant
  • Academic Emergency Medicine
    • Lammers, et al
    • January 2012
slide20

Drug Administration

Drug Administration

slide21

Drug Administration

Drug Administration

Diazepam

Needle

end

Volume remaining

Plunger direction

Needle

end

Volume delivered

toddler with anaphylactic shock
Toddler with Anaphylactic Shock
  • Epinephrine 1:1000 IM/SQ
    • Correct dose in 15 of 57 cases (26%)
    • 14 of 57 (25%) gave >10x protocol dose
    • 9 of 57 (16%) gave IV Epi (4 pushing 1:1000)
    • 3 of 5 agencies carried 30 mg multi-dose vials (1:1000)
  • Diphenhydramine IV/IO/IM
    • Correct dose in 7 of 54 cases (7%)
  • Solumedrol IV/IO
    • Only attempted by 3 of 60 crews (5%)
    • None with correct dose.
mi emsis peds seizure study
MI-EMSIS Peds Seizure Study
  • Retrospective review of Michigan EMS Information System
  • 2010 Statewide data
  • 944,415 EMS records (all ages)
  • 9,168 Under 2 years old (~1%)
  • 63 received a benzodiazepines (<7%) for seizure
benzo dosing
Benzo Dosing

Midazolam (N=28)

Diazepam (N=35)

IV/IO

2 of 6 (33%) Correct Dose

Rectal

5 of 13 (38%) Correct Dose

IM (wrong route)

1 patient

Active Error Rate=65%

  • IV/IO
    • 2 of 8 (25%) Correct Dose
  • IM
    • 3 of 11 (27%) Correct Dose
  • Rectal
    • 5 (18%) (wrong route)
  • Active Error Rate=79%
summary of studies
Summary of Studies
  • Hoyle Study: 23% to 100% dosing error rate
  • MI PEEDS Study: 25% to 93% dosing error rate
  • MI EMSIS Study: 62% to 75% dosing error rate
  • Studies limited to EMS (high performance EMS)
    • Do other health professionals do better?
implications in disaster medicine
Implications in Disaster Medicine
  • Higher than usual level of emotional stress
  • Emergency personnel task overloaded
  • Use of non-emergency personnel for augmentation
    • e.g., Ortho nurse pulled to ED
  • Need for highly potent meds with significant risks
    • Analgesics, sedatives, neuromuscular blockers, ACLS meds
  • Use of alternative, unfamiliar meds
  • Unknown pediatric patient weights
plan ahead minimizing risk of pediatric medication errors
Plan Ahead – Minimizing Risk of Pediatric Medication Errors
  • People
  • Practice and Practices
  • Protocols
  • Paraphernalia
people
People
  • Training and Education
    • Increased use of existing standardized courses (PALS/PEPP)
      • Increased emphasis on safe med administration
    • More frequent, brief continuing education sessions
      • 60 minutes twice a year vs. 4 hours every 2 years
    • Simulation-based training
      • High intensity, small group
      • Does not require high-fidelity simulators
slide29

Knowledge Assessment

Q. “What is the dose of Benadryl for an 8 kg infant who is in anaphylaxis?”

A. 1 mg/kg IM or IV

slide30

Performance-Based Assessment

Q. “This simulated infant is in anaphylaxis and has received epinephrine. An IV line is in place. Give another drug.”

slide31

Performance-Based Assessment

Answer:

1. Recall “Benadryl.”

2. Recall or look up the dose: 1 mg/kg IV.

3. Calculate the dose in mgs:

1 mg/kg x 8 kg = 8 mg

slide35

7. Find the closest port on the IV line.

8. Attach the syringe without contaminating the line.

9. Clamp the line upstream.

10. Deliver the entire volume.

practice and practices
Practice and Practices
  • Practice (Exercising)
    • Include peds in EMS and hospital exercises
    • Require simulated med administration
    • Use wireless ped simulators
  • Practices
    • Mandatory buddy-check for all pediatric med administration
      • Requires culture change
      • Challenges with single paramedic crews
    • No fault med error reporting systems
      • Provide info on near misses/hits >>>> Safety solutions
protocols
Protocols
  • Greatly simplify dosing protocols
    • Avoid non-whole numbers
    • Broad, simple doses
      • Epi-Pen vs. Epi-Pen Jr.
    • Use single doses when appropriate
      • Glucagon IM for hypoglycemia
  • Can this be done safely?
rampart study
RAMPART Study
  • Rapid Anticonvulsant Medications Prior to Arrival Trial
  • New England Journal of Medicine
    • Silbergliet, et al
    • Feb 16, 2012
  • Multi-Center Randomized Trial
    • Including Detroit EMS
    • Compare
      • Midazolam 10 mg IM
        • (13-40 kg 5 mg IM)
      • Lorazepam 4 mg IV
        • (13-40 kg 2 mg IV)

~.4 mg/kg

rampart findings
RAMPART Findings
  • Conclusion: For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation.
paraphernalia
Paraphernalia
  • Autoinjectors
    • Limited availability (Epi Pen, AtroPen, Glucagon +/-)
  • Broselow® Pediatric Emergency Tape
    • Limitations
  • Pediatric Dosing Cards
    • Under development
slide41

Thematic Qualitative Assessment

Thematic Qualitative Assessment

Equipment:

Use of Broselow tape for weight estimate:

Cognitive

error

Procedure

error

Procedure

error

End of tape

not aligned

with head

Unfamiliar with

Broselow tape

Wrong end of tape used

Wrong

Weight

Forgot to use

Broselow tape

Used mother’s

estimate rather than

Broselow tape

Cognitive

error

Cognitive

error

slide42

Thematic Qualitative Assessment

Thematic Qualitative Assessment

Drug Delivery:

Teamwork

error

Cognitive

error

Cognitive

error

Cognitive

and/or

procedure

error

Failure to cross-check

calculations

Mg to mL

conversion error

Unaided calculations

Wrong weight

Drug

Dose

Error

Mg/kg to mg

calculation error

Wrong mg/kg dose

for route

Impaired calculation

ability under stress

Volume measured from

wrong end of

pre-filled syringe

Drug

Dosing

Cards?

Cognitive

error

Cognitive

error

Affective

error

Procedure

error

summary
Summary
  • Caring for critically ill and injured kids is extremely stressful
    • Disasters greatly increase stress
  • Pediatric medication errors are common
    • During a disaster med errors could significantly increase
  • There are many ways to potentially reduce ped med errors
    • By reducing pediatric medication errors on a “routine” basis, we will provide safer, more effective care in a disaster

Thanks! Fales@kcms.msu.edu