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Plan Ahead – Minimizing the Risk of Pediatric Medication

ErrorsImplications for Disaster

Medicine William Fales, MD, FACEP

Michigan State University Kalamazoo Center for Medical Studies5th District Medical Response Coalition

Kalamazoo County Medical Control Authority

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

Nothing to Disclose

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Kids in Disasters

Fortunately

Mass Casualty IncidentsInvolving Children Are Relatively Uncommon

Also, Fortunately

Isolated Incidents Involving Critically Ill and Injured

Infants and ChildrenAre Relatively Uncommon

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”?

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Pediatric Medication Errors

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

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

95th %ile 50th

%ile

5th %ile

Age Distribution

Incorrect Medication Doses, Overdoses and

Underdoses

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 Pediatric Excellence and Error Detection with Simulation Study EMS-C Targeted Issues

Grant

Academic Emergency Medicine Lammers, et al January 2012

Participating Agencies

Mobile Pediatric Simulation Unit

Seizing InfantBenzo Dosing (N=45)

Drug AdministrationDrug Administration

Needleend

Needleend

Plunger direction

Diazepam

Volume delivered

Volume remaining

Drug Administration Drug Administration

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

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

Midazolam (N=28)

IV/IO 2 of 8 (25%) Correct

Dose IM

3 of 11 (27%) Correct Dose

Rectal 5 (18%) (wrong route)

Active Error Rate=79%

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%

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

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 People Practice and Practices Protocols Paraphernalia

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

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

Performance-Based

Assessment

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

Performance-Based

AssessmentAnswer:

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

4. Find the concentration on the bottle.

5. Convert a weight dose to a volume dose. 8 mg

50 mg/mL

= 0.16 mL

6. Draw 0.16 mL out of the vial with a 1 mL syringe.

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 (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

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?

~.4 mg/kg

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)

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

Autoinjectors Limited availability (Epi Pen, AtroPen,

Glucagon +/-) Broselow® Pediatric Emergency Tape

Limitations Pediatric Dosing Cards

Under development

Thematic Qualitative AssessmentThematic Qualitative Assessment

Wrong end

of tape used

End of tape

not alignedwith head

Forgot to use

Broselow tape

WrongWeight

Equipment:Use of Broselow tape for weight estimate:

Cognitiveerror

Procedureerror

Procedureerror

Used mother’s

estimate ra

ther than

Broselow tape

Cognitiveerror

Unfamiliar with

Broselow tape

Cognitiveerror

Thematic Qualitative AssessmentThematic Qualitative Assessment

Volume measured fro

m

wrong end of

pre-filled sy

ringe

Mg to mL

conversion error DrugDoseError

Wrong weight

Mg/kg to

mg

calcu

lation error

Unaided calculations

Failure to cross-check

calculations

Impaire

d calcu

lation

ability under s

tress

Affectiveerror

Teamworkerror

Cognitiveerror

Procedureerror

Cognitiveerror Cognitive

errorCognitive

and/orprocedure

error

Drug Delivery:

Wrong mg/kg

dose

for ro

ute

Cognitiveerror

DrugDosingCards?

LA County Peds Cards

6-7 Kg6-7 (13-15 Lbs)/ 3-6 Months(Pink)

Resuscitation Medication Dose VolumeEPINEPHRINE 1:10,000 (1mg/10mL prefill) .07 mg 0.7 mlAMIODARONE (150mg/3mL) 25 mg 0.5 mlLIDOCAINE (100mg/5mL) 5 mg 0.25 mlMAGNESIUM SULFATE (1gm/2mL) 250 mg 0.5 mlCALCIUM CHLORIDE (1gm/10mL) 100 mg 1 mlADENOSINE (6mg/2mL) – 1st Dose .65 mg 0.2 mlADENOSINE (6mg/2mL) – 2nd Dose 1.3 mg 0.4 mlElectrical Therapy Initial RepeatDefibrillation 15 J 25 JCardioversion (synchronized) 10 J 15 J

MI Peds Card (Prototype)

MI Peds Card (Prototype) 6-7 Kg (13-15 Lbs)/ 3-6 Months

(Pink)Assessment Normal Vitals: HR: 100-160, RR: 30-60, SBP: >70,

Development: Rolls from front to back, back to side. Carries object to mouth Drug Dose Volume Drug Dose Volume

AsthmaAnaphylaxis

Albuterol (2.5 mg/3 ml) 2.5 mg 3 ml Epinephrine (1 mg/ml) IM 0.1 mg 0.1 ml

Diphenhydramine (50 mg/ml) 10 mg 0.2 ml Solumedrol (125 mg/2 ml) 19 mg 0.3 ml

Seizure Midazolam IM (5 mg/1 ml) 1 mg 0.2 ml Diazepam PR (10 mg/2 ml) 3 mg 0.6 ml

Midazolam IV slow (5 mg/1 ml+4 ml NSS=1 mg/ml))

.5 mg 1 ml (diluted)

Diazepam IV slow (10 mg/2 ml + 8 ml NSS=1 mg/ml)

1 mg 1 ml(diluted

)Hypoglycemia

Dextrose 25% Slow IV 15 ml Glucagon IM (1 mg/ml) 1 mg 1 ml

Pain Control Fentanyl IV (100 mcg/2 ml) 5 mcg 0.1 ml Morphine IV (10 mg/ml + 9 ml NSS=10mg/10 ml)

0.5 mg .5 ml (diluted

)

Fentanyl IN(100 mcg/ml) 10 mcg .2 ml Morphine IM (10 mg/ml) 1 mg 0.1 ml

Narcotic OD Naloxone IV/IM (2 mg/2 ml) 1 mg 1 ml Naloxone IN (2 mg/2 ml) 1 mg 1 ml

Fluid Bolus Normal Saline IV/IO 130 ml 130 ml May repeat NSS x2 PRN 130 ml 130 ml

Equipment OPA: 50mm, NPA: 14F, BVM: Infant, Laryngoscope: 1 (straight), ET Tube: 3.5, ET Depth: 11 cm

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