Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

Simulation-Based Training to Improve Clinical Pharmacist Self-Efficacy in the Management of a Rapidly Decompensating Patient

Background: The optimal training method to prepare pharmacists as an integral rapid response team or cardiopulmonary arrest responders is poorly described. This study assessed the utility of simulation-based training (SBT) as a training technique for clinical pharmacists. Objective: This study aimed to determine if attending SBT is associated with an improvement in self-efficacy. Methods: This single-center, prospective, interventional cohort study offered three simulations to clinical pharmacists over the course of seven months at a 957-bed quaternary care academic medical center. Pharmacists who participated in at least one simulation were categorized in the intervention group and were compared to pharmacists who did not attend a simulation. All participants were asked to complete a 19-question self-efficacy survey in the form of a 100-point scale, a 15-question multiple-choice knowledge assessment, and a perception survey in the form of 4-point Likert scale administered at baseline and following the conclusion of the SBT. Results: Forty-four clinical pharmacists participated; 20 in the intervention group and 24 in the control group. Median change in self-efficacy score improved significantly in the intervention group compared to the control group (14.3 vs 2.3, P = .009). Median change in perception score improved significantly (2 vs 0, P = .046). Knowledge score did not change significantly from baseline. Conclusion: Simulation-based training improved clinical pharmacist self-efficacy and perceptions in the care of rapidly decompensating patients. These findings support SBT as a viable modality of training clinical pharmacists for the management of rapidly decompensating patients.

Nurses' knowledge and understanding of obstacles encountered them when administering resuscitation medications: a cross-sectional study from Palestine

BACKGROUND

Medication errors (ME) are one of the most important reasons for patient morbidity and mortality, but insufficient drug knowledge among nurses is considered a major factor in drug administration errors. Furthermore, the complex and stressful systems surrounding resuscitation events increase nursing errors.

AIMS

This study aimed to assess the knowledge about resuscitation medications and understand the obstacles faced by nurses when giving resuscitation medications. Additionally, errors in the reporting of resuscitation medication administration and the reasons that prevented nurses from reporting errors were investigated.

METHODS

A cross-sectional study was conducted in the West Bank, Palestine. Convenient sampling was used to collect data, which was collected via a face-to-face interview questionnaire taken from a previous study. The questionnaire consisted of five parts: demographic data, knowledge of resuscitation medications (20 true/false questions), self-evaluation and causes behind not reporting ME, with suggestions to decrease ME.

RESULTS

A total of 200 nurses participated in the study. Nurses were found to have insufficient knowledge about resuscitation medications (58.6%). A high knowledge score was associated with male nurses, those working in the general ward, the cardiac care unit (CCU), the intensive care unit (ICU) and the general ward. The main obstacles nurses faced when administering resuscitation medication were the chaotic environment in cardiopulmonary resuscitation (62%), the unavailability of pharmacists for a whole day (61%), and different medications that look alike in the packaging (61%). Most nurses (70.5%) hoped to gain additional training. In our study, we found no compatibility in the definition of ME between nurses and hospitals (43.5%).

CONCLUSIONS

Nurses had insufficient knowledge of resuscitation medications. One of the obstacles nurses faced was that pharmacists should appropriately arrange medications, and nurses wanted continuous learning and additional training about resuscitation medications to decrease ME.

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.

Skill acquisition of safe medication administration through realistic simulation: an integrative review

OBJECTIVE

to investigate evidence that indicates the contribution of realistic high, medium or low fidelity simulation to acquire knowledge, skills and attitudes in safe medication administration by nursing students.

METHODS

an integrative review of experimental studies from MEDLINE, LILACS, Web of Science, Scopus and Science Direct. The descriptors "nursing students", "simulation", "high fidelity simulation training", "medication errors" and "pharmacology" were used to identify 14 studies that answered the research question, and were assessed for accuracy methodological level and level of evidence.

RESULTS

there was a sample of quasi-experimental studies, (level 3 of evidence; 78.6%) and randomized clinical trials (level 2 of evidence; 21.4%), whose expressive majority showed superiority of the simulation strategy over the traditional methodology (71.4%).

CONCLUSION

using low and high fidelity simulators, standardized patients and virtual simulation can promote acquisition of essential skills for patient safety.

A Cognitive Aid for Neonatal Epinephrine Dosing

OBJECTIVES

Errors are common when preparing epinephrine for neonatal resuscitation. Epinephrine is available in two concentrations (1 mg/mL and 1 mg/10 mL) and requires weight-based calculations, which increases the risk of dosing errors. We developed a printed cognitive aid to assist with dose preparation. We hypothesized that the cognitive aid would result in a 25% difference in errors in preparing the dose of epinephrine during simulated neonatal resuscitation.

METHODS

Nurses (N = 100) in a large academic and community hospital were randomly assigned to calculate the intended dose and prepare epinephrine for neonatal resuscitation with or without the cognitive aid. Scenarios were video recorded and timed. Secondary outcomes included errors in the written intended dose, errors in choosing the correct epinephrine concentration, and time required to prepare the final dose. Proportions were compared by using Fisher's exact test. Variables influencing dosing errors were investigated by using logistic regression.

RESULTS

Using the cognitive aid significantly decreased the proportion of doses prepared incorrectly (24% vs 50%; P = .01). The aid also decreased errors in choosing the correct epinephrine concentration (12% vs 44%; P < .001), but there was no difference in the written intended dose or the time to prepare the dose. Years of experience, self-perceived math comfort, and anxiety were not predictive of dosing errors.

CONCLUSIONS

A simple cognitive aid decreased epinephrine dosing errors during simulated neonatal resuscitation but did not improve efficiency. Despite the effectiveness of the cognitive aid, errors were not completely eliminated. This is a serious safety risk for newborns and requires additional interventions.

Deviations from AHA guidelines during pediatric cardiopulmonary resuscitation are associated with decreased event survival

BACKGROUND

Deviations (DEVs) from resuscitation guidelines are associated with worse outcomes after adult in-hospital cardiac arrest (IHCA), but impact during pediatric IHCA is unknown.

METHODS

Retrospective cohort study of prospectively collected data from the American Heart Association's Get With The Guidelines-Resuscitation registry. Children who had an index IHCA of ≥1 min from 2000 to 2014 were included. DEVs are defined by the registry by category (airway, medications, etc.) A composite measure termed circulation DEV(C-DEV), defined as at least one process deviation in the following categories: medications, defibrillation, vascular access, or chest compressions, was the primary exposure variable. Primary outcome was survival to hospital discharge. Mixed-effect models with random intercept for each hospital assessed the relationship of DEVs with survival to hospital discharge. Robustness of findings was assessed via planned secondary analysis using propensity score matching.

RESULTS

Among 7078 eligible index IHCA events, 1200 (17.0%) had DEVs reported. Airway DEVs (466; 38.8%) and medication DEVs (321; 26.8%) were most common. C-DEVs were present in 629 (52.4%). Before matching, C-DEVs were associated with decreased rate of ROSC (aOR = 0.53, CI95: 0.43-0.64, p < 0.001) and survival to hospital discharge (aOR = 0.71, CI95: 0.60-0.86, p < 0.001). In the matched cohort (C-DEV n = 573, no C-DEV n = 1146), C-DEVs were associated with decreased rate of ROSC (aOR 0.76, CI95 0.60-0.96, p = 0.02), but no association with survival to hospital discharge (aOR 1.01, CI95 0.81-1.25, p = 0.96).

CONCLUSIONS

DEVs were common in this cohort of pediatric IHCA. In a propensity matched cohort, while survival to hospital discharge was similar between groups, events with C-DEVs were less likely to achieve ROSC.

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.

Assessment of cardiopulmonary resuscitation equipment in resuscitation trolleys in district hospitals in Botswana: A cross-sectional study

INTRODUCTION

Successful cardiopulmonary resuscitation (CPR) relies, in part, on the availability and the correct functioning of resuscitation equipment. These data are often lacking in resource-constrained African settings.

AIM

To assess the availability and the functional status of CPR equipment in resuscitation trolleys at district hospitals in Botswana.

SETTING

The study was conducted across four district hospitals in Botswana.

METHODS

A cross-sectional study was conducted using a checklist adopted following the Emergency Medical Services of South Africa (EMSSA) guidelines, modified and contextualised to Botswana.

RESULTS

All the four district hospitals had inadequate number of CPR equipment available in the resuscitation trolleys. The overall availability of drugs and equipment ranged from 19% to 31.1%. Availability of equipment needed for maintaining circulation and fluids ranged from 27% to 49%, while availability of items for airway and breathing ranged from 9.2% to 24.1%. The overall availability of essential drugs for resuscitation was only 20.4%, and in some wards expired drugs were kept in the trolley. Out of 40 wards that participated in the study, only 10 kept CPR algorithms in the resuscitation trolley. The resuscitation trolley was checked on a daily basis only in the critical care units.

CONCLUSION

The resuscitation trolleys were not maintained as per standards. Failure to improve the existing situation could negatively impact the outcome of CPR. Evidence-based standard checklists for resuscitation trolleys need to be enforced to improve the quality of CPR provision in district hospitals in Botswana.

Volume Versus Mass Dosing of Epinephrine for Neonatal Resuscitation: A Randomized Trial

BACKGROUND

Intravenous epinephrine for neonatal resuscitation requires weight-based calculations. Epinephrine is available in 2 different concentrations, increasing the risk of dosing errors. Expert panels have conflicting recommendations for the ordering method. The Neonatal Resuscitation Program recommends the volume (milliliters per kilogram) method, whereas the Institute for Safe Medication Practices recommends the mass (milligrams per kilogram) method. In this study, we aim to determine if the mass method is more accurate and efficient than the volume method.

METHODS

In a randomized crossover simulation study, 70 NICU and pediatric emergency department nurses calculated the intended dose then prepared epinephrine using both the mass and volume methods. Both epinephrine concentrations were available. Scenarios were video recorded and timed. The primary outcome was the proportion of epinephrine doses prepared correctly. Variables associated with correct dosing were analyzed by using logistic regression.

RESULTS

Of 136 total doses, 77 (57%) were prepared correctly. The correct intended dose was calculated more frequently by using the mass method (82% vs 68%; risk difference 15%; 95% confidence interval 3% to 26%), but there was no difference in the proportion of doses that were actually prepared correctly (53% of mass method doses versus 60% of volume method doses; risk difference -7%; 95% confidence interval -24% to 9%). There was no difference between methods in the time required to prepare the dose. Selecting the correct epinephrine concentration was the only variable associated with correct dosing.

CONCLUSIONS

The mass method was neither more accurate nor more efficient. Nurses made frequent errors when using both methods. This is a serious patient safety risk. Additional educational and medication safety interventions are urgently needed.

Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors

BACKGROUND

Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty.

METHODS

With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution.

RESULTS

A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021).

CONCLUSIONS

Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.

Interprofessional Simulations Promote Knowledge Retention and Enhance Perceptions of Teamwork Skills in a Surgical-Trauma-Burn Intensive Care Unit Setting

BACKGROUND

The current state of health care encompasses highly acute, complex patients, managed with ever-changing technology. The ability to function proficiently in critical care relies on knowledge, technical skills, and interprofessional teamwork. Integration of these factors can improve patient outcomes. Simulation provides "hands-on" practice and allows for the integration of teamwork into knowledge/skill training. However, simulation can require a significant investment of time, effort, and financial resources. The Institute of Medicine recommendations from 2015 include "strengthening the evidence base for interprofessional education (IPE)" and "linking IPE with changes in collaborative behavior." In one surgical-trauma-burn intensive care unit (STBICU), no IPE existed. The highly acute and diverse nature of the patients served by the unit highlights the importance of appropriate training. This is heightened during critical event situations where patients deteriorate rapidly and the team intervenes swiftly.

PURPOSE

The aims of this study were to (1) evaluate knowledge retention and analyze changes in perceptions of teamwork among nurses and resident physicians in a STBICU setting after completion of an interprofessional critical event simulation and (2) provide insight for future interprofessional simulations (IPSs), including the ideal frequency of such training, associated cost, and potential effect on nursing turnover.

DESIGN

A comparison-cohort pilot study was developed to evaluate knowledge retention and analyze changes in perceptions of teamwork.

METHODS

A 1-hour critical event IPS was held for nurses and resident physicians in a STBICU setting. A traumatic brain injury patient with elevated intracranial pressure, rapid deterioration, and cardiac arrest was utilized for the simulation scenario. The simulation required the team to use interventions to reduce elevated intracranial pressure and then perform cardiac resuscitation according to Advanced Cardiac Life Support guidelines. A semistructured debriefing guided by the TENTS tool highlighted important aspects of teamwork. Participants took knowledge and Teamwork Skills Scale (TSS) pretests, posttests, and 1-month posttests. Mean scores were calculated for each time point (pre, post, and 1-month post), and paired t tests were used to evaluate changes.

RESULTS

Mean knowledge test and TSS scores both significantly increased after the simulation and remained significantly elevated at 1-month follow-up. Participants recommended retraining intervals of 3 to 6 months. Cost of each simulation was estimated to be $324.44. Analysis of nursing turnover rates did not demonstrate a statistically significant reduction in turnover; however, confounding factors were not controlled for.

CONCLUSION

Significant improvements on both knowledge test and TSS scores demonstrate the effectiveness of the intervention, and retention of the information gained and teamwork skills learned. Participants valued the intervention and recommended to increase the frequency of training. Future studies should develop a framework for "best practice" IPS, analyze the relationship with nursing turnover, and ultimately seek correlations between IPS and improved patient outcomes.

Making care better in the pediatric intensive care unit

The relatively young field of pediatric critical care has seen a shift from an approach with little consideration for the complications and adverse effects resulting from the procedures and medications to a more cautious approach with careful concern for the associated risks. Many senior pediatric intensivists recall a time when nearly every patient had a central venous line and arterial line; and hospital acquired infections, pressure injuries, unplanned extubations, and venous thromboemboli were expected costs of aggressive care. In addition to the morbidity and mortality associated with many of the health care-acquired conditions (HACs) in children, the attributable cost due to these HACs contributes to the unsustainable health care financial crisis. The Centers for Medicare and Medicaid Services (CMS) often penalize hospitals for HACs, and also are beginning to reimburse in a bundled fashion such that complications become the institution's burden. In children, payors and patients' families are often saddling this burden of costs attributable to HACs. The direct attributable costs per event are staggering. Payors, families, patients, and health care teams now demand a circumspect approach to care: do no harm, but how?

Medication Errors in the Emergency Department: Knowledge, Attitude, Behavior, and Training Needs of Nurses

Aim:

The aim was to describe which elements of nurses' knowledge, training needs, behavior, and attitude can prevent Medication errors (Acronym MEs) in the emergency department during all steps of the administration of intravenous (IV) medications.

Methods:

An anonymous questionnaire made up of 43 items has been drafted and delivered to a sample of 103 nurses of a university hospital in Rome. The study has been supported by specific literature review.

Results:

Majority of the sample (94%) answered that topics related to the preparation and administration of IV medications were covered during the basic course while 63.2% only during the postbasic course. Only 15.6% of nurses judged excellent their level of knowledge about preparation and administration of IV medications while 89.3% considered that it is important to improve their knowledge; 85.6% said that the teaching about the use of IV medications should be increased during the degree course they attended; 30.3% agreed that specific postgraduate courses on the use of IV drugs should be designed. Moreover, only 22% of the sample believed that the coaching of new recruit nurses is critical to prevent errors.

Conclusion:

The sample showed appropriate knowledge, positive attitudes, and right behavior related to the preparation and administration of IV medications. The skills that nurses must have in pharmacology are still rising, both due to the safety of drug therapy and to the increasing number of drugs available; the result is that nurses have to update their knowledge regularly.

[Materials for the paediatric resuscitation trolley or backpack: Expert recommendations]

Cardio-respiratory arrest (CPA) is infrequent in children, but it can occur in any place and at any time. This fact means that every health care facility must always have the staff and material ready to resuscitate a child. These recommendations are the consensus of experts of the Spanish Paediatric and Neonatal Resuscitation Group on the material and medication for paediatric and neonatal resuscitation and their distribution and use. CPR trolleys and backpacks must include the essential material to quickly and efficiently perform a paediatric CPR. At least one CPR trolley must be available in every Primary Care facility, Paediatric Intensive Care Unit, Emergency Department, and Pre-hospital Emergency Areas, as well as in paediatric wards, paediatric ambulatory areas, and radiology suites. This trolley must be easily accessible and exclusively include the essential items to perform a CPR and to assist children (from newborns to adolescents) who present with a life-threatening event. Such material must be familiar to all healthcare staff and also include the needed spare parts, as well as enough drug doses. It must also be re-checked periodically. The standardisation and unification of the material and medication of paediatric CPR carts, trolleys, and backpacks, as well as the training of the personnel in their use are an essential part of the paediatric CPR.

Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial

OBJECTIVE

To evaluate whether a clinical aid providing precalculated medication doses decreases prescribing errors among residents during pediatric simulated cardiopulmonary arrest and anaphylaxis.

METHODS

A crossover randomized trial was conducted in a tertiary care hospital simulation center with residents rotating in the pediatric emergency department. The intervention was a reference book providing weight-based precalculated doses. The control group used a card providing milligram-per-kilogram doses. The primary outcome was the presence of a prescribing error, defined as a dose varying by ≥20% from the recommended dose or by incorrect route. Residents were involved in 2 sets of paired scenarios and were their own control group. Primary analysis was the difference in mean prescribing error proportions between both groups.

RESULTS

Forty residents prescribed 1507 medications or defibrillations during 160 scenarios. The numbers of prescribing errors per 100 bolus medications or defibrillations were 5.1 (39 out of 762) and 7.5 (56 out of 745) for the intervention and control, respectively, a difference of 2.4 (95% confidence interval [CI], -0.1 to 5.0). However, the intervention was highly associated with lower risk of 10-fold error for bolus medications (odds ratio 0.27; 95% CI, 0.10 to 0.70). For medications administered by infusion, prescribing errors occurred in 3 out of 76 (4%) scenarios in the intervention group and 13 out of 76 (22.4%) in the control group, a difference of 13% (95% CI, 3 to 23).

CONCLUSIONS

A clinical aid providing precalculated medication doses was not associated with a decrease in overall prescribing error rates but was highly associated with a lower risk of 10-fold error for bolus medications and for medications administered by continuous infusion.