Journal Watch: Reducing Pediatric Medication Errors

Reviewed This Month

• Medication Errors in Pediatric Patients After Implementation of a Field Guide With Volume-Based Dosing
• Authors: Rappaport LD, Markowitz G, Hulac S, Roosevelt G
• Published in: Prehospital Emergency Care, January 2022

The rarity of prehospital encounters with severely ill or injured pediatric patients can make it difficult for EMS providers to maintain medical knowledge, skill, and confidence when caring for children. Therefore, it should not be surprising that studies have reported medication dosing errors for these prehospital patients. While in the hospital environment providers can have assistance like automated drug dispensing and pharmacist-verified doses, EMS has relatively few support mechanisms to aid in medication dosing accuracy. EMS does have length/weight-based tape (LBT), and the use of this tape or other “appropriate reference material” has been recommended in a policy statement by the National Association of EMS Physicians. 

The authors of the study we review this month examined the percentage of correct pediatric medication doses following implementation of the Handtevy field guide. The authors note the field guide includes an LBT based on age, specific age-appropriate vital signs, equipment recommendations by age, and a customized preprinted medication guide based on the institution’s formulary. The field guide provides the weight-based dose and precalculated medication doses in milliliters by age. The authors hypothesized that implementation of the field guide would increase the percentage of correct pediatric medication doses to greater than 85% from baseline. 

Study Parameters

This study was a retrospective cohort study that included all medications administered to patients less than 13 years of age. Patients receiving nebulized medications, those for whom medical direction was called, and cases where the medication indication fell outside the field guide protocols were excluded from the analysis. The study was conducted in a single-tier all-ALS EMS system that utilized BLS for first response. This system was the sole provider of 9-1-1 services to its city and surrounding county. The service area was 154.7 square miles, with a population estimated to be about 700,000 in 2018. There were 215 paramedics in the system. The annual call volume was 118,000. 

The field guide was introduced into the system in 2015. The study period was from July 2017 to June 2019. These data were compared to baseline data from 2014. The primary outcome was the percentage of correct doses. Using previous literature as their guide, the authors defined a correct dose as administering a dose of 80%–120% of the field guide dose by age. For the baseline period the correct dose was defined as administering a dose within 80%–120% of the calculated correct dose based on recorded weight.

Correct dosing using the field guide can be determined by age or use of the LBT. The authors indicated the paramedic would initially ask the parent or caretaker for an age. The LBT was only used if no one on scene could provide the age of the child. During the baseline period paramedics asked for the child’s weight, utilized an LBT, or estimated the weight based on the child’s size. 

One of the authors reviewed all EMS records for the study period to identify dosing errors. If a medication error was identified, a second author reviewed the record for confirmation. For the baseline period, an author reviewed all records from January to July 2014 and another reviewed all records from June through December 2014. The authors note that there was 100% agreement between the reviewers for June 2014. 

During the field guide study period, there were 7591 patient encounters with children less than 13 years of age. Of these, 8% (608) had a medication administered. There were 233 encounters excluded, leaving 483 medications administered to 375 patients for analysis. The baseline and field guide populations were similar in age and gender (P>.05). During the baseline period there were 274 medications administered during 206 patient encounters. The median age during the baseline period was 8.9 years. The median age during the field guide study period was 8.2 years. During the baseline period 61% (126) of the population was male. During the field guide period, 58% (218) was male. Race and ethnicity were not collected during the baseline period, so comparisons were not possible. 

Results

During the field guide period, doses were correct in 89% of medication administrations, with 65% of doses documented exactly as dictated by the field guide. During the baseline period 51% of medications were administered with the correct dose (P<.001). Patients were 1.8 times (95% CI 1.6–2.0) more likely to receive the correct dose during the field guide period compared to the baseline period (P<.001). There was a statistically significant improvement (P<.05) in the percentage of correct doses for administrations of epinephrine 1:1000 (IM), epinephrine 1:10,000 (IV/IO), fentanyl (IN and IV), methylprednisolone (IV), and midazolam (IM and IV/IO). No significant difference (P>.05) was noted with administrations of adenosine (IV), dextrose 10% (IV), diphenhydramine (IM and IV), midazolam (IN), naloxone (IN/IV), and ondansetron (IV). 

Overall, incorrect doses were given in 11% of medication administrations during the field guide period. There were 4% overdoses of medication in the field guide period compared to 31% in the baseline period (P<.001). The authors note the largest overdose during the study period was a single administration of 3 times the appropriate dose of solumedrol. There were also 4 occurrences of patients receiving twice the appropriate dose of fentanyl. Intranasal midazolam (12%) and IV fentanyl (9%) were the most overdosed medications. The largest underdose of medication during the field guide period was a 10-fold underdose of IM epinephrine 1:1000. The most underdosed medications were IN midazolam (24%) and IM epinephrine 1:1000. Finally, the highest percentage of errors was seen in the 0–1-year-old age group, with 3 of 15 incorrect doses. 

Conclusion

The authors note their study is limited by the inclusion of only a single EMS system. Furthermore, the study did not directly observe the medication administration; it is possible a paramedic may have administered an incorrect dose while thinking the correct dose was administered and reported the correct dose in the documentation. 

Nevertheless, this is an important addition to the literature that supports the use of a field guide with precalculated doses as an effective tool for reducing pediatric medication dosing errors by EMS providers. I congratulate the authors on publishing their work!  

Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and serves on the board of advisors of the Prehospital Care Research Forum at UCLA.