Color-coded prefilled medication syringes decrease time to delivery and dosing errors in simulated prehospital pediatric resuscitations: A randomized crossover trial☆,☆
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).
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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.
References (30)
- et al.
A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group
Ann Emerg Med
(1988) Error and time delay in pediatric trauma resuscitation: addressing the problem with color-coded resuscitation aids
Surg Clin N Am
(2002)- et al.
Potential medication dosing errors in outpatient pediatrics
J Pediatr
(2005) - et al.
Eliminating errors in emergency medical services: realities and recommendations
Prehosp Emerg Care
(2002) - et al.
Medication calculation skills of practicing paramedics
Prehosp Emerg Care
(2000) - et al.
Errors during the preparation of drug infusions: a randomized controlled trial
Br J Anaesth
(2012) - et al.
Medication errors observed in 36 health care facilities
Arch Intern Med
(2002) - et al.
Tenfold medication errors: 5 years’ experience at a university-affiliated pediatric hospital
Pediatrics
(2012) - et al.
The incidence and nature of prescribing and medication administration errors in paediatric inpatients
Arch Dis Child
(2010) - et al.
Medication dosing errors in pediatric patients treated by emergency medical services
Prehosp Emerg Care
(2012)
Medication errors and adverse drug events in pediatric inpatients
JAMA
Medication errors in mental healthcare: a systematic review
Qual Saf Health Care
Medication errors among acutely ill and injured children treated in rural emergency departments
Ann Emerg Med
To Err is Human: Building a Safer Health System
Parental weight estimation of their child's weight is more accurate than other weight estimation methods for determining children's weight in an emergency department?
Emerg Med J
Cited by (0)
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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.
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Presented, in part, at the American Heart Association Resuscitation Science Symposium, Los Angeles, CA, November 4, 2012.