Review Of: Hoyle JD, Davis A, Putman K, et al. Medication dosing errors in pediatric patients treated by emergency medical services. Prehosp Emerg Care. 2012;16(1):59–66.
This is a retrospective analysis of medication dosing errors in pediatric patients by EMS providers over a two-year study period. Data was contributed by eight ambulance services in the state of Michigan, which combined for more than 163,000 calls during that time period, of which 5,547 patients met the initial inclusion criteria. Of the study population, 230 patients received one of the following medications: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and/or naloxone for a total of 360 medication administrations.
Overall, 125 of the 360 doses had errors or 35%, which is defined as a difference greater than 20% of the dose. The investigators conclude that administration of medication to pediatric patients is often not delivered at the correct dose and that EMS ought to take steps in reducing those errors.
Dr. Wesley: Medication dosing errors are a major quality of care concern for all patients, but especially for pediatric patients for whom both underdosing and overdosing can result in significant harm. This study highlights several specific concerns that an EMS medical director should have when providing agencies with patient care protocols.
First, how often will the providers use them? Epinephrine and atropine are primarily administered in cardiac arrest, which represent less than 5% of EMS calls and less than 1% of pediatric arrests. The authors found that dosing errors were highest for epinephrine and atropine, particularly for ages less than three, and that underdosing was significantly more likely to occur than overdosing. No correlation was made to epinephrine dosing error and the use of the Broselow Tape.
One possible reason for the errors is that the State EMS Protocol in effect at the time used two different epinephrine concentrations: 1:10,000 for the first dose and 1:1,000 for all subsequent doses. It has been my experience that multiple drug concentrations used during the same high stress patient encounter often result in confusion.
This may have explained the medication errors for dextrose because services were allowed to carry both D25 and D50, but those using D50 were required to first dilute it to 50/50 before administration.
Second, the authors speculate that lack of experience with pediatric resuscitation and minimal hours of continuing education may be to blame for the high rate or medication errors. Although they noted that the average number of hours of pediatric education was approximately four hours yearly, they didn’t specify what kind of education it was. Perhaps pediatric advanced life support (PALS) should be required as is ACLS by almost every state for paramedic licensure. PALS places great emphasis on proper drug calculations.
Finally, we must seriously examine the environment of EMS medication administration and look for innovative ways to provide medics with the tools necessary to avoid complex drug calculations, such as mandatory use of the Broselow Tape or other ready-references.
Medic Marshall: Although I’m generally in agreement with the Doc, I do have to say I’m slightly alarmed by this study. For me, it definitely calls to attention the need for improved oversight and quality improvement initiatives in the quality of care provided by EMS.
Regardless of the environment we work in, we’re still responsible for the care we provide to our patients, and we must do it to the best of our abilities. However, I also recognize the problems pediatric patients present to EMS: We just don’t see enough to stay proficient at assessing and caring for them.
Here’s how I see it: The number of patients under the age of 11 in this study was about 5,500—of which 230 received one or multiple doses of medication. That means that only 4% of the study population actually received at least one medication. Furthermore, 5,500 is only 3.4% or 163,000 when you look at the number of patients who actually received at least one dose of medication, 230, that number only equates to 0.14% of the total population. Is anyone else seeing a trend here? And this is over a two-year study period.
Hopefully I made my point. We really don’t see enough pediatric patients to stay proficient. In my opinion, it’s no wonder medications that were administered incorrectly by EMS were found to be incorrect 32% of the time.
So, although I agree with the Doc on requiring PALS for paramedics, I believe we need to go even further with our training and education in regards to pediatrics as well as developing and finding new tools for EMS to better improve the quality of care we provide.
Background: Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by EMS paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients.
Objective: To characterize medication dosing errors in children treated by EMS.
Methods: We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight appropriate dose, as determined by the patient’s reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine and naloxone.
There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (°æ standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% °æ 428%. The mean error (°æ standard deviation) for IV/IM 1:1000 epinephrine underdoses was 35.5% °æ 27.4%.
Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing error.