Iatrogenic pediatric hydroxocobalamin overdose

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review

INTRODUCTION

There is limited research available on safe medication management practices in EMS practice, with most evidence-based medication safety guidelines based on research in nursing, operating theatre and pharmacy settings. Prevention of errors requires recognition of contributing factors across the spectrum from the organizational level to procedural elements and patient characteristics. Evidence is inconsistent regarding the incidence of medication errors and multiple sources also state that errors are under-reported, making the true magnitude of the problem difficult to quantify. Definitions of error also vary, with the specific context of medication errors in prehospital practice yet to be established. The objective of this review is to identify the factors influencing the occurrence of medication errors by EMS personnel in the prehospital environment.

METHODS AND ANALYSIS

The review included both qualitative and quantitative research involving interventions or phenomena related to medication safety or medication error by EMS personnel in the prehospital environment. A search of multiple databases was conducted to identify studies meeting these inclusion criteria. All studies selected were assessed for methodological quality, however this was not used as a basis for exclusion. Each stage of study selection, appraisal and data extraction was conducted by two independent reviewers, with a third reviewer deciding any unresolved conflicts. The review follows a convergent integrated approach, conducting a single qualitative synthesis of qualitative and "qualitized" quantitative data.

RESULTS

56 articles were included in the review, with case reports and qualitative studies being the most frequent study types. Qualitative analysis revealed seven major themes: organizational factors (with reporting as a sub-theme), equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors (with pediatrics as a sub-theme) and cognitive factors. Both contributing factors and protective factors were identified.

DISCUSSION

The body of evidence regarding medication errors is heterogenous and limited in both quantity and quality. Multiple factors influence medication errors occurrence; knowledge of these is necessary to mitigate the risk of errors. Medication error incidence is difficult to quantify due to inconsistent measure, definitions and contexts of research conducted to date. Further research is required to quantify the prevalence of identified factors in specific practice settings.