Elsevier

Resuscitation

Volume 96, November 2015, Pages 85-91
Resuscitation

Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial,

https://doi.org/10.1016/j.resuscitation.2015.07.035Get rights and content

Abstract

Background

Medication dosing errors remain commonplace and may result in potentially life-threatening outcomes, particularly for pediatric patients where dosing often requires weight-based calculations. Novel medication delivery systems that may reduce dosing errors resonate with national healthcare priorities. Our goal was to evaluate novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape, compared to conventional medication administration, in simulated prehospital pediatric resuscitation scenarios.

Methods

We performed a prospective, block-randomized, cross-over study, where 10 full-time paramedics each managed two simulated pediatric arrests in situ using either prefilled, color-coded syringes (intervention) or their own medication kits stocked with conventional ampoules (control). Each paramedic was paired with two emergency medical technicians to provide ventilations and compressions as directed. The ambulance patient compartment and the intravenous medication port were video recorded. Data were extracted from video review by blinded, independent reviewers.

Results

Median time to delivery of all doses for the intervention and control groups was 34 (95% CI: 28–39) seconds and 42 (95% CI: 36–51) seconds, respectively (difference = 9 [95% CI: 4–14] seconds). Using the conventional method, 62 doses were administered with 24 (39%) critical dosing errors; using the prefilled, color-coded syringe method, 59 doses were administered with 0 (0%) critical dosing errors (difference = 39%, 95% CI: 13–61%).

Conclusions

A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by paramedics during simulated prehospital pediatric resuscitations.

Introduction

Medication errors are committed by healthcare providers, including physicians, nurses and paramedics, in virtually all healthcare settings.1, 2, 3, 4, 5, 6, 7 Since the release of the Institute of Medicine's (IOM) 1999 report addressing errors in healthcare, increased emphasis has been placed on reducing medical errors from faulty processes, systems, and environments that lead well-meaning clinicians to make mistakes or fail to prevent them.8

One of the highest risks for medication error exists during pediatric emergencies, particularly in the prehospital setting. A single paramedic is often exclusively responsible for gathering and analyzing pertinent information, making prompt decisions, and performing advanced interventions prior to the transfer of a critically ill patient to the emergency department (ED). Often this must be done amidst social chaos and under psychologically stressful conditions, increasing the potential for medication errors.

The color-coded Broselow™ Pediatric Emergency Tape (Vital Signs, Inc., Totowa, NJ) was developed to standardize both weight assessment and drug dosing for pediatric patients in a successful effort to decrease dosing errors. It is one of the most reliable and commonly used tools for pediatric resuscitations.9, 10, 11, 12 Unfortunately, this approach does not eliminate dosing errors as clinicians must still determine the volumes of medications from ampoules in order to deliver the correct dose. Translation of medications from the Broselow Tape has been proposed; yet to our knowledge, no one has attempted to develop color-coded, prefilled syringes that could be used in conjunction with the Broselow Tape to facilitate timely and accurate drug administration in the prehospital environment.13

The objective of this study was to compare novel, prefilled medication syringes labeled with color-coded volumes corresponding to the weight-based dosing of the Broselow Tape to conventional methods of drug administration in simulated prehospital pediatric resuscitations. We hypothesized that time of preparation to administration of drugs would be shorter, and the proportion of dosing errors would be lower when using prefilled, color-coded syringes (intervention) when compared to conventional medication preparations (control).

Section snippets

Study design

We performed a prospective, block-randomized, cross-over study with data collected during two standardized simulated pediatric cardiac arrest scenarios on May 17, 2011 and repeated on June 16, 2011 (Fig. 1). The prehospital environment was recreated by conducting simulations in situ, or inside working, off duty ambulances, with the same medication kits used in the field. Consistent with standard practice, we provided two firefighter/emergency medical technicians to assist with resuscitation by

Results

Ten paramedic participants completed both study days. Median age of participants was 31 (IQR: 28–37) years and 8 (80%) had between 6 and 15 years of experience. 132 doses of medications were administered, 69 (52%) using the conventional delivery method and 63 (48%) using the prefilled, color-coded syringe method. Two doses of naloxone were given during scenarios using the conventional method but were excluded from analyses as matching color-coded syringes were not created for this study. During

Discussion

Conducted in a prehospital setting, this study shows the use of a novel prefilled, color-coded syringe system reduces time required to prepare and deliver medications, reduces overall dosing errors, and eliminates critical dosing errors during simulated pediatric resuscitations by eliminating calculation as part of the cognitive process, utilizes pediatric specific volume preparations, and employs color designations identifying correct medication volumes. To our knowledge, this is the first

Conclusions

In summary, a novel color-coded prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by paramedics during simulated prehospital pediatric resuscitations. Implementing standardized, mechanically and visually simple systems that eliminate calculations during prehospital management of pediatric emergencies may facilitate appropriate patient care and contribute to improved outcomes.

Authors’ contributions

Mr. Stevens and Dr. Haukoos had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analyses. Color-coded syringe design: Hernandez. Study concept: Hernandez, Haukoos. Study design: Stevens, Hernandez, Jones, Blumen, Moreira, Hopkins, Sande, Bakes, Haukoos. Acquisition of data: Stevens, Hernandez, Jones, Blumen, Sande. Statistical analyses: Stevens, Hopkins, Haukoos. Interpretation of results: Stevens, Hernandez,

Funding

This study was funded by an unrestricted grant from the COPIC Medical Foundation, Denver, CO. The COPIC Medical Foundation had no role in the design, conduct, or reporting of this study. Dr. Haukoos was supported, in part, by an Independent Scientist Award (K02HS017526) from the Agency for Healthcare Research and Quality and an Investigator-Initiated Grant (R01AI106057) from the National Institutes of Health. No other authors were directly or indirectly supported by funding during this study.

Acknowledgments

We would like to thank Christine Black, Mark Brownson, Claire Chappell, Amy Dear-Ruel, Melissa O’Meara, Ramya Mishra, Adam Plate, and Ashley Phipps for their participation as research assistants; Kevin Kaucher, PharmD for development of study materials including medication vials; Comilla Sasson, MD, MS, PhD for her suggestions related to the manuscript; and the EMTs and firefighters who assisted as scenario team members, and the paramedics who participated as study subjects.

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  • Cited by (0)

    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.07.035.

    Presented, in part, at the American Heart Association Resuscitation Science Symposium, Los Angeles, CA, November 4, 2012.

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