Medication errors in pediatric emergencies: a systematic analysis

Is there evidence that length-based tapes with precalculated drug doses increase the accuracy of drug dose calculations in children? A systematic review

OBJECTIVE

The use of pediatric length-based weight estimation tapes with precalculated drug doses is advocated by major Advanced Life Support organizations, but concerns have been raised on the accuracy of these systems. The objective of this systematic review was to collect, review, evaluate, and create a synthesis of the current literature to establish whether there is high-quality evidence for use of length-based tapes in accurate drug dose administration. A further objective was to compare these tapes with other dosing aids.

METHODS

Eligible studies were identified and analyzed if they were peer reviewed, full text articles containing original data. Studies including any form of length-based precalculated drug dosing methodology in children aged 0 to 18 years were included.

RESULTS

Eighteen studies met the inclusion criteria. The most studied of the tapes was the Broselow tape in 16 studies (88.9%). When these tapes were used on their own without additional reference material, they produced a substantial number of potentially harmful dosing errors (>20% error). No tape was superior to another. Using the tapes was better than using no dosing aid but was inferior to using both comprehensive drug dosing guides and novel color-coded medication administration systems.

CONCLUSION

There was no high-quality evidence that the use of length-based tapes with precalculated drug doses leads to accurate drug dosing. However, comprehensive drug dosing systems were more effective at reducing dosing errors than were length-based tapes on their own. The confounding effect of weight estimation accuracy on drug dosing accuracy has not been sufficiently studied.

Medication errors in the practice of paediatric anaesthesia - a narrative review

Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Impact of a Mobile App on Paramedics' Perceived and Physiologic Stress Response During Simulated Prehospital Pediatric Cardiopulmonary Resuscitation: Study Nested Within a Multicenter Randomized Controlled Trial

BACKGROUND

Out-of-hospital cardiac arrests (OHCAs) are stressful, high-stake events that are associated with low survival rates. Acute stress experienced in this situation is associated with lower cardiopulmonary resuscitation performance in calculating drug dosages by emergency medical services. Children are particularly vulnerable to such errors. To date, no app has been validated to specifically support emergency drug preparation by paramedics through reducing the stress level of this procedure and medication errors.

OBJECTIVE

This study aims to determine the effectiveness of an evidence-based mobile app compared with that of the conventional preparation methods in reducing acute stress in paramedics at the psychological and physiological levels while safely preparing emergency drugs during simulated pediatric OHCA scenarios.

METHODS

In a parent, multicenter, randomized controlled trial of 14 emergency medical services, perceived and physiologic stress of advanced paramedics with drug preparation autonomy was assessed during a 20-minute, standardized, fully video-recorded, and highly realistic pediatric OHCA scenario in an 18-month-old child. The primary outcome was participants' self-reported psychological stress perceived during sequential preparations of 4 intravenous emergency drugs (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate) with the support of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app designed to help pediatric drug preparation (intervention) or conventional methods (control). The State-Trait Anxiety Inventory and Visual Analog Scale questionnaires were used to measure perceived stress. The secondary outcome was physiologic stress, measured by a single continuous measurement of the participants' heart rate with optical photoplethysmography.

RESULTS

From September 3, 2019, to January 21, 2020, 150 advanced paramedics underwent randomization. A total of 74 participants were assigned to the mobile app (intervention group), and 76 did not use the app (control group). A total of 600 drug doses were prepared. Higher State-Trait Anxiety Inventory-perceived stress increase from baseline was observed during the scenario using the conventional methods (mean 35.4, SD 8.2 to mean 49.8, SD 13.2; a 41.3%, 35.0 increase) than when using the app (mean 36.1, SD 8.1 to mean 39.0, SD 8.4; a 12.3%, 29.0 increase). This revealed a 30.1% (95% CI 20.5%-39.8%; P<.001) lower relative change in stress response in participants who used the app. On the Visual Analog Scale questionnaire, participants in the control group reported a higher increase in stress at the peak of the scenario (mean 7.1, SD 1.8 vs mean 6.4, SD 1.9; difference: -0.8, 95% CI -1.3 to -0.2; P=.005). Increase in heart rate during the scenario and over the 4 drugs was not different between the 2 groups.

CONCLUSIONS

Compared with the conventional method, dedicated mobile apps can reduce acute perceived stress during the preparation of emergency drugs in the prehospital setting during critical situations. These findings can help advance the development and evaluation of mobile apps for OHCA management and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.

Automated Size Recognition in Pediatric Emergencies Using Machine Learning and Augmented Reality: Within-Group Comparative Study

Background

Pediatric emergencies involving children are rare events, and the experience of emergency physicians and the results of such emergencies are accordingly poor. Anatomical peculiarities and individual adjustments make treatment during pediatric emergency susceptible to error. Critical mistakes especially occur in the calculation of weight-based drug doses. Accordingly, the need for a ubiquitous assistance service that can, for example, automate dose calculation is high. However, few approaches exist due to the complexity of the problem.

Objective

Technically, an assistance service is possible, among other approaches, with an app that uses a depth camera that is integrated in smartphones or head-mounted displays to provide a 3D understanding of the environment. The goal of this study was to automate this technology as much as possible to develop and statistically evaluate an assistance service that does not have significantly worse measurement performance than an emergency ruler (the state of the art).

Methods

An assistance service was developed that uses machine learning to recognize patients and then automatically determines their size. Based on the size, the weight is automatically derived, and the dosages are calculated and presented to the physician. To evaluate the app, a small within-group design study was conducted with 17 children, who were each measured with the app installed on a smartphone with a built-in depth camera and a state-of-the-art emergency ruler.

Results

According to the statistical results (one-sample t test; P=.42; α=.05), there is no significant difference between the measurement performance of the app and an emergency ruler under the test conditions (indoor, daylight). The newly developed measurement method is thus not technically inferior to the established one in terms of accuracy.

Conclusions

An assistance service with an integrated augmented reality emergency ruler is technically possible, although some groundwork is still needed. The results of this study clear the way for further research, for example, usability testing.

Effect of a Mobile App on Prehospital Medication Errors During Simulated Pediatric Resuscitation: A Randomized Clinical Trial

IMPORTANCE

Medication errors are a leading cause of injury and avoidable harm, affecting millions of people worldwide each year. Children are particularly susceptible to medication errors, but innovative interventions for the prevention of these errors in prehospital emergency care are lacking.

OBJECTIVE

To assess the efficacy of an evidence-based mobile app in reducing the occurrence of medication errors compared with conventional preparation methods during simulated pediatric out-of-hospital cardiac arrest scenarios.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, open-label, multicenter, randomized clinical trial was conducted at 14 emergency medical services centers in Switzerland from September 3, 2019, to January 21, 2020. The participants were 150 advanced paramedics with drug preparation autonomy. Each participant was exposed to a 20-minute, standardized, fully video-recorded, realistic pediatric out-of-hospital cardiac arrest cardiopulmonary resuscitation scenario concerning an 18-month-old child. Participants were tested on sequential preparations of 4 intravenous emergency drugs of varying degrees of preparation difficulty (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate).

INTERVENTION

Participants were randomized (1:1 ratio) to the support of an app designed to assist with pediatric drug preparation (intervention; n = 74) or to follow conventional drug preparation methods without assistance (control; n = 76).

MAIN OUTCOMES AND MEASURES

The primary outcome was the rate of medication errors, defined as a failure in drug preparation according to predefined, expert consensus-based criteria. Logistic regression models with mixed effects were used to assess the effect of the app on binary outcomes. Secondary outcomes included times to drug preparation and delivery, assessed with linear regression models with mixed effects.

RESULTS

In total, 150 advanced paramedics (mean [SD] age, 35.6 [7.2] years; 101 men [67.3%]; mean [SD] time since paramedic certification, 8.0 [6.2] years) participated in the study and completed 600 drug preparations. Of 304 preparations delivered using the conventional method, 191 (62.8%; 95% CI, 57.1%-68.3%) were associated with medication errors compared with 17 of 296 preparations delivered using the app (5.7%; 95% CI, 3.4%-9.0%). When accounting for repeated measures, with the app, the proportion of medication errors decreased in absolute terms by 66.5% (95% CI, 32.6%-83.8%; P < .001), the mean time to drug preparation decreased by 40 seconds (95% CI, 23-57 seconds; P < .001), and the mean time to drug delivery decreased by 47 seconds (95% CI, 27-66 seconds; P < .001). The risk of medication errors varied across drugs with conventional methods (19.7%-100%) when compared with the app (4.1%-6.8%).

CONCLUSIONS AND RELEVANCE

Compared with conventional methods, the use of a mobile app significantly decreased the rate of medication errors and time to drug delivery for emergency drug preparation in a prehospital setting. Dedicated mobile apps have the potential to improve medication safety and change practices in pediatric emergency medicine.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03921346.

Comparison of Accuracy and Speed in Computer-Assisted Versus Conventional Methods for Pediatric Drug Dose Calculation: A Scenario-Based Randomized Controlled Trial

Pediatric emergency care is prone to medication errors in many aspects including prescriptions, administrations, and monitoring. This study was designed to assess the effects of computer-assisted calculation on reducing error rates and time to prescription of specific emergency drugs. We conducted a randomized crossover experimental study involving emergency medicine residents and paramedics in the Department of Emergency Medicine at Ramathibodi Hospital. Participants calculated and prescribed medications using both the conventional method and a computer-assisted method. Medication names, dosages, routes of administration, and time to prescription were collected and analyzed using logistic and quantile regression analysis. Of 562 prescriptions, we found significant differences between computer-assisted calculation and the conventional method in the calculation accuracy of overall medications, pediatric advanced life support (PALS) drugs, and sedative drugs (91.17% vs 67.26%, 86.54% vs 46.15%, and 89.29% vs 57.86%, respectively, P < .001). Moreover, there were significant differences in calculation time for overall medications, PALS drugs and sedative drugs (25 vs 47 seconds, P < .001), and computer-assisted calculation significantly decreased the gap in medication errors between doctors and paramedics (P < .001). We conclude that computer-assisted prescription calculation provides benefits over the conventional method in accuracy of all medication dosages and in time required for calculation, while enhancing the drug prescription ability of paramedics.

Interventions to Reduce Medication Dispensing, Administration, and Monitoring Errors in Pediatric Professional Healthcare Settings: A Systematic Review

Introduction: Pediatric patients cared for in professional healthcare settings are at high risk of medication errors. Interventions to improve patient safety often focus on prescribing; however, the subsequent stages in the medication use process (dispensing, drug administration, and monitoring) are also error-prone. This systematic review aims to identify and analyze interventions to reduce dispensing, drug administration, and monitoring errors in professional pediatric healthcare settings. Methods: Four databases were searched for experimental studies with separate control and intervention groups, published in English between 2011 and 2019. Interventions were classified for the first time in pediatric medication safety according to the "hierarchy of controls" model, which predicts that interventions at higher levels are more likely to bring about change. Higher-level interventions aim to reduce risks through elimination, substitution, or engineering controls. Examples of these include the introduction of smart pumps instead of standard pumps (a substitution control) and the introduction of mandatory barcode scanning for drug administration (an engineering control). Administrative controls such as guidelines, warning signs, and educational approaches are lower on the hierarchy and therefore predicted by this model to be less likely to be successful. Results: Twenty studies met the inclusion criteria, including 1 study of dispensing errors, 7 studies of drug administration errors, and 12 studies targeting multiple steps of the medication use process. A total of 44 interventions were identified. Eleven of these were considered higher-level controls (four substitution and seven engineering controls). The majority of interventions (n = 33) were considered "administrative controls" indicating a potential reliance on these measures. Studies that implemented higher-level controls were observed to be more likely to reduce errors, confirming that the hierarchy of controls model may be useful in this setting. Heterogeneous study methods, definitions, and outcome measures meant that a meta-analysis was not appropriate. Conclusions: When designing interventions to reduce pediatric dispensing, drug administration, and monitoring errors, the hierarchy of controls model should be considered, with a focus placed on the introduction of higher-level controls, which may be more likely to reduce errors than the administrative controls often seen in practice. Trial Registration Prospero Identifier: CRD42016047127.

Changes in transfusion and fluid therapy practices in severely injured children: an analysis of 5118 children from the TraumaRegister DGU®

Purpose

Trauma is the leading cause of death in children. In adults, blood transfusion and fluid resuscitation protocols changed resulting in a decrease of morbidity and mortality over the past 2 decades. Here, transfusion and fluid resuscitation practices were analysed in severe injured children in Germany.

Methods

Severely injured children (maximum Abbreviated Injury Scale (AIS) ≥ 3) admitted to a certified trauma-centre (TraumaZentrum DGU®) between 2002 and 2017 and registered at the TraumaRegister DGU® were included and assessed regarding blood transfusion rates and fluid therapy.

Results

5,118 children (aged 1–15 years) with a mean ISS 22 were analysed. Blood transfusion rates administered until ICU admission decreased from 18% (2002–2005) to 7% (2014–2017). Children who are transfused are increasingly seriously injured. ISS has increased for transfused children aged 1–15 years (2002–2005: mean 27.7–34.4 in 2014–2017). ISS in non-transfused children has decreased in children aged 1–15 years (2002–2005: mean 19.6 to mean 17.6 in 2014–2017). Mean prehospital fluid administration decreased from 980 to 549 ml without affecting hemodynamic instability.

Conclusion

Blood transfusion rates and amount of fluid resuscitation decreased in severe injured children over a 16-year period in Germany. Restrictive blood transfusion and fluid management has become common practice in severe injured children. A prehospital restrictive fluid management strategy in severely injured children is not associated with a worsened hemodynamic state, abnormal coagulation or base excess but leads to higher hemoglobin levels.

Prevalence of Medication Errors Among Paediatric Inpatients: Systematic Review and Meta-Analysis

INTRODUCTION

The risk of medication errors is high in paediatric inpatient settings. However, estimates of the prevalence of medication errors have not accounted for heterogeneity across studies in error identification methods and definitions, nor contextual differences across wards and the use of electronic or paper medication charts.

OBJECTIVE

Our aim was to conduct a systematic review and meta-analysis to provide separate estimates of the prevalence of medication errors among paediatric inpatients, depending on hospital ward and the use of electronic or paper medication charts, that address differences in error identification methods and definitions.

METHODS

We systematically searched five databases to identify studies published between January 2000 and December 2018 that assessed medication error rates by medication chart audit, direct observation or a combination of methods.

RESULTS

We identified 71 studies, 19 involved paediatric wards using electronic charts. Most studies assessed prescribing errors with few studies assessing administration errors. Estimates varied by ward type. Studies of paediatric wards using electronic charts generally reported a reduced error prevalence compared to those using paper, although there were some inconsistencies. Error detection methods impacted the rate of administration errors in studies of multiple wards, however, no other difference was found. Definition of medication error did not have a consistent impact on reported error rates.

CONCLUSIONS

Medication errors are a frequent occurrence in paediatric inpatient settings, particularly in intensive care wards and emergency departments. Hospitals using electronic charts tended to have a lower rate of medication errors compared to those using paper charts. Future research employing controlled designs is needed to determine the true impact of electronic charts and other interventions on medication errors and associated harm among hospitalized children.

Drug dosing errors in simulated paediatric emergencies - Comprehensive dosing guides outperform length-based tapes with precalculated drug doses

BACKGROUND

The accuracy of drug dosing calculations during medical emergencies in children has not been evaluated extensively. The objectives of this study were to evaluate the accuracy of drug dose calculations using the Broselow tape, the PAWPER XL tape plus its companion drug-dosing guide, a custom-designed mobile phone app and no drug-dosing aid (control group).

METHODS

This was a prospective study in which 32 emergency medicine volunteers participated in eight simulations of common paediatric emergency conditions, using children models. The participants used the three methods to estimate the children's weight and calculate drug doses. The accuracy of and time taken for the drug dose determinations were then evaluated for each of the methods.

RESULTS

The overall accuracy of drug dose determinations was extremely and potentially dangerously low in the control group in which no dosing guide was used as well as in the Broselow tape group (<20% of doses were correct). The accuracy was significantly higher with the PAWPER XL tape group and the mobile app group (47% and 31% respectively). The times taken to obtain the required information did not differ in a clinically meaningful magnitude.

CONCLUSIONS

Both an accurate weight estimation and a dosing guide with comprehensive information were necessary to produce an accurate prescription. The information on the Broselow tape was not sufficient for this purpose. The current guidelines recommending the use of tapes with limited information should be revised. The results from the comprehensive dosing guides were substantially better, but still had a lower proportion of accurate prescriptions than desirable. The role of training in every aspect of the emergency paediatric weight estimation and drug dosing procedure cannot be underestimated and should be routine in any environment where emergency care may be needed.

A mobile device app to reduce prehospital medication errors and time to drug preparation and delivery by emergency medical services during simulated pediatric cardiopulmonary resuscitation: study protocol of a multicenter, prospective, randomized controlled trial

BACKGROUND

Emergency drug preparation and administration in children is both complex and time-consuming and places this population at a higher risk than adults for medication errors. Moreover, survival and a favorable neurological outcome from cardiopulmonary resuscitation are inversely correlated to drug preparation time. We developed a mobile device application (the pediatric Accurate Medication IN Emergency Situations (PedAMINES) app) as a step-by-step guide for the preparation to delivery of drugs requiring intravenous injection. In a previous multicenter randomized trial, we reported the ability of this app to significantly reduce in-hospital continuous infusion medication error rates and drug preparation time compared to conventional preparation methods during simulation-based pediatric resuscitations. This trial aims to evaluate the effectiveness of this app during pediatric out-of-hospital cardiopulmonary resuscitation.

METHODS/DESIGN

We will conduct a multicenter, prospective, randomized controlled trial to compare the PedAMINES app with conventional calculation methods for the preparation of direct intravenously administered emergency medications during standardized, simulation-based, pediatric out-of-hospital cardiac arrest scenarios using a high-fidelity manikin. One hundred and twenty paramedics will be randomized (1:1) in several emergency medical services located in different regions of Switzerland. Each paramedic will be asked to prepare, sequentially, four intravenously administered emergency medications using either the app or conventional methods. The primary endpoint is the medication error rates. Enrollment will start in mid-2019 and data analysis in late 2019. We anticipate that the intervention will be completed in early 2020 and study results will be submitted in late 2020 for publication (expected in early 2021).

DISCUSSION

This clinical trial will assess the impact of an evidence-based mobile device app to reduce the rate of medication errors, time to drug preparation and time to drug delivery during prehospital pediatric resuscitation. As research in this area is scarce, the results generated from this study will be of great importance and may be sufficient to change and improve prehospital pediatric emergency care practice.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03921346. Registered on 18 April 2019.

[Safety of Pharmacotherapy in Emergencies]

Safety of Pharmacotherapy in Emergencies Abstract. Emergency pharmacotherapy is one of the most commonly used medical procedures. At the same time, pharmacotherapy in an emergency is always a potentially dangerous action. Medication errors are even among the most frequently registered errors in medicine. Due to the special circumstances in emergency medicine, special precautions are required to ensure the safety of drug therapy. In addition to the important background information, this article presents procedures that are recognized and applicable in daily routine to increase safety in pharmacotherapy.

An algorithm to improve the accuracy of emergency weight estimation in obese children

Introduction

During medical emergencies in children, accurate and appropriate weight estimations may ultimately influence the outcome by facilitating the delivery of safe and effective doses of medications. Children at the extremes of habitus, especially obese children, are more at risk of an inaccurate weight estimation and therefore may be more at risk of medication errors. The objective was therefore to develop an algorithm to guide accurate emergency weight estimation in obese children.

Methods

Relevant medical evidence was reviewed regarding weight estimation and its role and timing in the resuscitation of obese children. This was used as the basis for a weight-estimation algorithm.

Results

There was limited evidence regarding the way the weight-estimation systems should be used in obese children other than that the dual length- and habitus-based systems were the most accurate. The methods included in the algorithm were the Broselow tape, the Mercy method, parental estimates, the paediatric advanced weight prediction in the emergency room/ eXtra Length-eXtra Large (PAWPER XL) tape and the Traub-Johnson formula. The algorithm recognised several ways in which weight estimation could be tailored to the clinical scenario to estimate both ideal and total body weight.

Conclusion

Weight-estimation in obese children must be conducted appropriately to avoid medication errors. This algorithm provides a framework to achieve this.

Validation of a mobile app for reducing errors of administration of medications in an emergency

Medication errors occur frequently and are a risk to patient safety. To reduce mistakes in the medication process in emergencies, a mobile app has been developed supporting the calculation of doses and administration of drugs. A simulation study was performed to validate the app as a tool to reduce medication errors. This was a randomised crossover study conducted in the Academic Hospital. The participants included were residents and attendings in anaesthesiology. 74 Participants performed four simulation scenarios in which they had to calculate and administer drugs for emergencies. Two scenarios were performed with the app ("app scenarios") and the other two scenarios were performed without the use of the app ("control scenarios"). The order of drugs, simulation patients and usage of aid were randomized. The accuracy of administered drug doses were measured. Medications were categorised as either "accurate" ([Formula: see text]% of target dosage) or "wrong" (less than 50% or more than 200% of target dosage). The dosage calculated and the dosage administered were documented separately to differentiate between calculation and handling errors. During app scenarios, there were no "wrong" dosages, whereas 6.8 (95% CI 2.7-10.8%) of dosages in control scenarios were evaluated as "wrong". The probability of giving an "accurate" dosage was increased from 77.7 (70.9-84.5%) in control scenarios to 93.9 (90-97.8%) in app scenarios. Calculation errors were the main cause for wrong dosing. The app is an appropriate and feasible tool to reduce calculation and handling errors and may increase patient safety.

The accuracy of paediatric weight estimation during simulated emergencies: The effects of patient position, patient cooperation, and human errors

INTRODUCTION

The effect of patient position and patient cooperation on the accuracy of emergency weight estimation systems has not been evaluated previously. The objective of this study was to evaluate weight estimation accuracy of the Broselow tape, the PAWPER XL tape, the Mercy method, and a custom-designed mobile phone App in a variety of realistic simulated paediatric emergencies.

METHODS

This was a prospective study in which 32 emergency medicine volunteers participated in eight simulations of common paediatric emergency conditions, using children models. The participants used each of the four methods to estimate the children's weight. The accuracy of and time taken for the weight estimations were evaluated for each method. A regression analysis determined the effects of patient position and cooperation on weight estimation accuracy. Evaluation of subgroups of best-performers and worst-performers among the participants provided information on the effects of human user-error on weight estimation accuracy.

RESULTS

The Broselow tape, Mercy method, App and the PAWPER XL tape achieved percentages of weight estimation within 10% of actual weight in 47.7, 57.3, 68.1, and 73.0% of estimations, respectively. Patient position and cooperation strongly impacted the accuracy of the Broselow tape, had a minimal effect on the Mercy method and the App, and had no effect on the PAWPER XL tape. The best performing participants achieved very high accuracy with all methods except the Broselow tape.

DISCUSSION

The Mercy method, the App, and the PAWPER XL tape achieved exceptionally high accuracy even in uncooperative and sub-optimally positioned children when used by the best-performing participants. Human error, from inexperience and inadequate training, had the most significant impact on accuracy. The Mercy method was the most subject to human error, and the PAWPER XL tape, the least. Adequate training in using weight estimation systems is essential for paediatric patient safety.

Accuracy of weight estimation by the Broselow tape is substantially improved by including a visual assessment of body habitus

BackgroundThe Broselow tape (BT) has been shown to estimate weight poorly primarily because of variations in body habitus. The manufacturers have suggested that a visual assessment of habitus may be used to increase its performance. This study evaluated the ability of habitus-modified models to improve the accuracy thereof.MethodsA post hoc analysis of prospectively collected data from four hospitals in Johannesburg, South Africa, on a population of 1,085 children. Sixteen a priori models generated a modified weight estimation or drug dose based on the BT weight and a gestalt assessment of habitus.ResultsThe habitus-modified method suggested by the manufacturer did not improve the accuracy of the BT. Five dosing and four weight-estimation models were identified that markedly improved dosing and weight estimation accuracy, respectively. The best dosing model improved dosing accuracy (doses within 10% of correct dose) from 52.0 to 69.6% and reduced critical dosing errors from 16.5 to 4.3%. The best weight-estimation model improved accuracy from 59.4 to 81.9% and reduced critical errors from 11.8 to 1.9%.ConclusionThe accuracy of the BT as a drug-dosing and weight-estimation device can be substantially improved by including an appraisal of body habitus in the methodology.

A Mobile Device App to Reduce Medication Errors and Time to Drug Delivery During Pediatric Cardiopulmonary Resuscitation: Study Protocol of a Multicenter Randomized Controlled Crossover Trial

BACKGROUND

During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusions is complex and time-consuming. The need for individual specific weight-based drug dose calculation and preparation places children at higher risk than adults for medication errors. Following an evidence-based and ergonomic driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion. In a prior single center randomized controlled trial, medication errors were reduced from 70% to 0% by using PedAMINES when compared with conventional preparation methods.

OBJECTIVE

The purpose of this study is to determine whether the use of PedAMINES in both university and smaller hospitals reduces medication dosage errors (primary outcome), time to drug preparation (TDP), and time to drug delivery (TDD) (secondary outcomes) during pediatric CPR when compared with conventional preparation methods.

METHODS

This is a multicenter, prospective, randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drug infusion rate table in the preparation of continuous drug infusion. The evaluation setting uses a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin. The study involving 120 certified nurses (sample size) will take place in the resuscitation rooms of 3 tertiary pediatric emergency departments and 3 smaller hospitals. After epinephrine-induced return of spontaneous circulation, nurses will be asked to prepare a continuous infusion of dopamine using either PedAMINES (intervention group) or the infusion table (control group) and then prepare a continuous infusion of norepinephrine by crossing the procedure. The primary outcome is the medication dosage error rate. The secondary outcome is the time in seconds elapsed since the oral prescription by the physician to drug delivery by the nurse in each allocation group. TDD includes TDP. Stress level during the resuscitation scenario will be assessed for each participant by questionnaire and recorded by the heart rate monitor of a fitness watch. The study is formatted according to the Consolidated Standards of Reporting Trials Statement for Randomized Controlled Trials of Electronic and Mobile Health Applications and Online TeleHealth (CONSORT-EHEALTH) and the Reporting Guidelines for Health Care Simulation Research.

RESULTS

Enrollment and data analysis started in March 2017. We anticipate the intervention will be completed in late 2017, and study results will be submitted in early 2018 for publication expected in mid-2018. Results will be reported in line with recommendations from CONSORT-EHEALTH and the Reporting Guidelines for Health Care Simulation Research .

CONCLUSIONS

This paper describes the protocol used for a clinical trial assessing the impact of a mobile device app to reduce the rate of medication errors, time to drug preparation, and time to drug delivery during pediatric resuscitation. As research in this area is scarce, results generated from this study will be of great importance and might be sufficient to change and improve the pediatric emergency care practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03021122; https://clinicaltrials.gov/ct2/show/NCT03021122 (Archived by WebCite at http://www.webcitation.org/6nfVJ5b4R).

A smartphone application to determine body length for body weight estimation in children: a prospective clinical trial

The aim of this study was to test the feasibility and accuracy of a smartphone application to measure the body length of children using the integrated camera and to evaluate the subsequent weight estimates. A prospective clinical trial of children aged 0-<13 years admitted to the emergency department of the University Children's Hospital Zurich. The primary outcome was to validate the length measurement by the smartphone application «Optisizer». The secondary outcome was to correlate the virtually calculated ordinal categories based on the length measured by the app to the categories based on the real length. The third and independent outcome was the comparison of the different weight estimations by physicians, nurses, parents and the app. For all 627 children, the Bland Altman analysis showed a bias of -0.1% (95% CI -0.3-0.2%) comparing real length and length measured by the app. Ordinal categories of real length were in excellent agreement with categories virtually calculated based upon app length (kappa = 0.83, 95% CI 0.79-0.86). Children's real weight was underestimated by physicians (-3.3, 95% CI -4.4 to -2.2%, p < 0.001), nurses (-2.6, 95% CI -3.8 to -1.5%, p < 0.001) and parents (-1.3, 95% CI -1.9 to -0.6%, p < 0.001) but overestimated by categories based upon app length (1.6, 95% CI 0.3-2.8%, p = 0.02) and categories based upon real length (2.3, 95% CI 1.1-3.5%, p < 0.001). Absolute weight differences were lowest, if estimated by the parents (5.4, 95% CI 4.9-5.9%, p < 0.001). This study showed the accuracy of length measurement of children by a smartphone application: body length determined by the smartphone application is in good agreement with the real patient length. Ordinal length categories derived from app-measured length are in excellent agreement with the ordinal length categories based upon the real patient length. The body weight estimations based upon length corresponded to known data and limitations. Precision of body weight estimations by paediatric physicians and nurses were comparable and not different to length based estimations. In this non-emergency setting, parental weight estimation was significantly better than all other means of estimation (paediatric physicians and nurses, length based estimations) in terms of precision and absolute difference.

[Use of cognitive aids in pediatric emergency care : Interdisciplinary consensus statement]

Preclinical pediatric emergencies are rare events and are therefore often associated with stress and uncertainty for emergency medical service personnel. To ensure adequate treatment of pediatric patients a variety of different cognitive aids exist (e.g. books, apps, rulers, weight-adapted bag systems). Especially the size specifications of the medical equipment and the dosage of emergency medication are individually very different in children and are dependent on parameters, such as body height and weight. Therefore, cognitive aids often enable length measurement whereby it is possible to draw conclusions on body weight for calculating the child's medication dosage. These aids may help to avoid the wrong medication dose or the wrong therapy of children but uncritical and untrained usage of these aids carries a potential risk of mistakes. This recommendation gives an overview of the general requirements and different problems of cognitive aids and should help improve the general framework and the rational basis for the use and further development of cognitive aids in emergency medicine.

A Mobile Device App to Reduce Time to Drug Delivery and Medication Errors During Simulated Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Background

During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion.

Objective

The aim of our study was to determine whether the use of PedAMINES reduces drug preparation time (TDP) and time to delivery (TDD; primary outcome), as well as medication errors (secondary outcomes) when compared with conventional preparation methods.

Methods

The study was a randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drugs infusion rate table in the preparation of continuous drug infusion. We used a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin in the shock room of a tertiary care pediatric emergency department. After epinephrine-induced return of spontaneous circulation, pediatric emergency nurses were first asked to prepare a continuous infusion of dopamine, using either PedAMINES (intervention group) or the infusion table (control group), and second, a continuous infusion of norepinephrine by crossing the procedure. The primary outcome was the elapsed time in seconds, in each allocation group, from the oral prescription by the physician to TDD by the nurse. TDD included TDP. The secondary outcome was the medication dosage error rate during the sequence from drug preparation to drug injection.

Results

A total of 20 nurses were randomized into 2 groups. During the first study period, mean TDP while using PedAMINES and conventional preparation methods was 128.1 s (95% CI 102-154) and 308.1 s (95% CI 216-400), respectively (180 s reduction, P=.002). Mean TDD was 214 s (95% CI 171-256) and 391 s (95% CI 298-483), respectively (177.3 s reduction, P=.002). Medication errors were reduced from 70% to 0% (P<.001) by using PedAMINES when compared with conventional methods.

Conclusions

In this simulation-based study, PedAMINES dramatically reduced TDP, to delivery and the rate of medication errors.

The Safety of Drug Therapy in Children

BACKGROUND

1.7% of children taking medication on an outpatient basis in Germany have at least one adverse drug reaction (ADR). The corresponding figure for hospitalized children is estimated at 10% .

METHODS

This review is based on pertinent literature retrieved by a selective search in PubMed.

RESULTS

According to reports submitted to the Drug Commission of the German Medical Association (Arzneimittelkommission der deutschen Ärzteschaft, AkdÄ), serious ADRs can arise, for example, after the administration of dimenhydrinate, α-adrenergic nose drops, enemas containing phosphate, ACE inhibitors, angiotensin-2-receptor antagonists (sartans), and methylphenidate. The causes of ADRs include overdoses, drug administration despite contraindications, and inadequate monitoring of long-term treatment. Errors can also be made in communication, labeling, and drug administration. The risk of ADRs is especially high in off-label use. Computerized physician order entry systems, individual packaging and labeling of single doses, and the use of bar codes for patient and drug identification can help prevent such errors.

CONCLUSION

The process of drug administration should be optimized through suitable interventions and electronic support, with due consideration of local circumstances. Clinical trials on children should be encouraged as a means of improving drug safety, and additional financial incentives should be created for trials concerning drugs that are off-patent. Physicians and pharmacists should take care to report adverse reactions as they are required to do by professional code, particularly in the case of new drugs, off-label use, or medication errors. A recognized national standard for dosing that can be implemented in computerized physician order entry systems is needed so that evidence-based pediatric dosages can be calculated.

[Typical problems in pediatric emergencies: Possible solutions]

BACKGROUND

Pediatric emergencies are rare and challenging for health care providers, parents, and patients. The purpose of this article is to highlight typical difficulties in the treatment of pediatric patients and to discuss potential solutions.

MATERIALS AND METHODS

This article is based on a selective literature search using PubMed and the experience of the authors in the field of simulation and pediatric emergencies.

RESULTS

Inexperience with pediatric emergencies, uncertainty in technical skills, in the usage of pediatric equipment and in medication dosage as well as parental presence foster the perception of stress and potentially compromise the success of patient care. Beside implementation of simplified technical skill devices (e.g., intraosseous vascular access system, supraglottic airway devices, and alternative approaches for drug administration), there have been many efforts in recent years to improve patient safety. Tools for estimating body weight and precalculated drug-dosing charts have been implemented as well as standardized courses for guidelines, technical skills, and team-related skills have been established.

CONCLUSION

To improve patient safety, regular training and implementation of a sustainable safety culture are mandatory.