Objectives: Systematic evaluation of prehospital provider performance during actual resuscitations is difficult. Although prior studies reported pediatric drug-dosing mistakes and other types of management errors, the underlying causes of those errors were not investigated. The objective of this study was to identify causes of errors during a simulated, prehospital pediatric emergency.Methods: Two-person emergency medical services (EMS) crews from five geographically diverse agencies participated in a validated simulation of an infant with altered mental status, seizures, and respiratory arrest using their own equipment and drugs. A scoring protocol was used to identify errors. A debriefing conducted by a trained facilitator immediately after the simulated event elicited root causes of active and latent errors, which were analyzed by thematic qualitative assessment methods.Results: Forty-five crews completed the study. Clinically important themes that emerged from the data included oxygen delivery, equipment organization and use, glucose measurement, drug administration, and inappropriate cardiopulmonary resuscitation. Delay in delivery of supplemental oxygen resulted from two different automaticity errors and a 54% failure rate in using an oropharyngeal airway (OPA). Most crews struggled to locate essential pediatric equipment. Three found broken or inoperable bag ⁄ -valve ⁄ masks (BVMs), resulting in delayed ventilation. Some mistrusted their intraosseous (IO) injection gun device; others used it incorrectly. Only 51% of crews measured blood glucose; some discovered that glucometers were not stored in their sealed pediatric bags. The error rate for diazepam dosing was 47%; for midazolam, it was 60%. Underlying causes of dosing errors were found in four domains (cognitive, procedural, affective, and teamwork), and they included incorrect estimates of weight, incorrect use of the Broselow pediatric emergency tape, faulty recollection of doses, difficulty with calculations under stress, mg ⁄ kg to mg to mL conversion errors, inaccurate measurement of volumes, use of the wrong end of prefilled syringes, and failure to crosscheck doses with partners.Conclusions: Simulation, followed immediately by facilitated debriefing, uncovered underlying causes of active cognitive, procedural, affective, and teamwork errors, latent errors, and error-producing conditions in EMS pediatric care.ACADEMIC EMERGENCY MEDICINE 2012; 19:37-47 ª 2012 by the Society for Academic Emergency Medicine L ittle is known about medical errors that involve children who receive care in emergency departments (EDs), and even less is known about pediatric errors in the prehospital setting. The substrate for errors in an ED is well known. Patients are unfamiliar to health care providers; complaints are diverse; problems are complex, often serious, and sometimes emotionally charged; information is limited; interruptions are too frequent; and time pressures are always present.

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Multiple deficiencies in paramedics' performance of pediatric resuscitation skills were objectively identified using three manikin-based simulations. EMS educators and EMS medical directors should target these specific skill deficiencies when developing continuing education in prehospital pediatric patient care.

Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.

Medical simulation is a rapidly expanding area within medical education. In 2005, the Society for Academic Emergency Medicine Simulation Task Force was created to ensure that the Society and its members had adequate access to information and resources regarding this new and important topic. One of the objectives of the task force was to create a research agenda for the use of simulation in emergency medical education. The authors present here the consensus document from the task force regarding suggested areas for research. These include opportunities to study reflective experiential learning, behavioral and team training, procedural simulation, computer screen-based simulation, the use of simulation for evaluation and testing, and special topics in emergency medicine. The challenges of research in the field of simulation are discussed, including the impact of simulation on patient safety. Outcomes-based research and multicenter efforts will serve to advance simulation techniques and encourage their adoption.

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