Opportunities for performance improvement in relation to medication administration during pediatric stabilization

Abstract

Objectives: To identify and characterize areas for improvement in the clinical performance of nurses in relation to medication administration. Method: Nurses participated in a simulated pediatric stabilization event which was videotaped. Their clinical performance was evaluated at each of the following steps: (1) communicating and confirming the dose of medication; (2) converting the dose; (3) selecting the correct medications; (4) properly preparing the medication formulation; and (5) measuring medication doses. The time required to convert and draw up the medications was also evaluated. Results: A total of 150 medication orders for five medications were given by the physician. Only 55% of the orders were verbally repeated back by the nurses. Of the 120 orders in which the doses were converted from milligrams to milliliters by nurses, 17 (14.2%) were converted incorrectly and the maximum dose deviation reached 400%. Selection of the wrong medication occurred in 11 of the 150 orders. Dextrose (which requires dilution before being administered to children) was not diluted in 17% of the medication orders and in 12% it was diluted improperly. About 40% of the orders for ceftriaxone (which requires reconstitution) were not properly reconstituted. In 49 (32.7%) of the 150 medication orders that were drawn up in a syringe, the amount measured was not consistent with the stated dose. For some medications, a prolonged time was required by nurses to convert the doses and draw up the medications. Conclusions: By observing the clinical performance of nurses in a simulated videotaped pediatric stabilization event, we have identified some important areas in need of improvement in each step of the medication administration process. These findings indicate a need for improved education, training, and use of clinical aids or adjuncts for pediatric emergency nurses. M edication errors are among the most frequently reported errors in the pediatric emergency setting. Kozer et al 1 found that approximately 10% of children treated in the emergency department were subject to medication error. The risk of medication error is even more profound when children require resuscitation and emergency stabilization. This is because stabilization events are stressful and highly variable situations during which healthcare providers must make rapid decisions and react promptly to patients' needs, often with only limited information.1 Over the past few years, several safety initiatives and clinical tools have been developed and implemented to help decrease medication errors during pediatric stabilization events. One of the most widely used tools is the Broselow-Luten Emergency Tape (Vital Signs Inc, NJ, USA). Studies have shown that this tape, which provides pre-calculated medication doses based on children's weight, is effective in reducing medication error during simulated pediatric stabilization scenarios. Nurses play a very important role during pediatric stabilization events and delivery of medications is one of many important tasks required...

Patient Safety in the Pediatric Emergency Care Setting

“…Observational studies of simulated pediatric emergency events have identified problems with dosing of medications 22 and conversion of medication doses ordered in units by weight (eg, milligrams) to the appropriate number of units by volume (eg, milliliters), depending on the formulation of the drug. 23 These studies have also described a prolonged period of time required to calculate doses and administer certain critical medications. 22,23 …”

“…23 These studies have also described a prolonged period of time required to calculate doses and administer certain critical medications. 22,23 …”

“…There is currently no clinical tool universally available to ED nurses that provides them with this critical information, and a recent study of a simulated pediatric emergency event suggests that errors may occur at this point in the process of emergent medication administration. 23 Many hospitals and health care systems are developing and/or implementing CPOE systems. Currently, few systems are available that provide precalculated doses of medications based on a weight that is entered into the system.…”

Current status of administration of medicines

“…Furthermore, 32.7% of drug doses drawn up in a syringe were incorrect. 24 One study demonstrated that 81% of nurses were unable to correctly calculate medications 90% of the time and that 43.5% of test scores requiring calculations were below 70% accuracy. 25 In the United States, a nationwide study conducted to assess practices to validate mathematical skills indicated a required passing rate of 80%; no respondent institutions required 100% accuracy.…”

Optimizing Emergency Drug Dosing in Children

“…The reference material should therefore include not only the actual milligram dosage of a drug to administer (based on a milligram per kilogram body weight dose), but the exact method of dilution required (if necessary) and also the exact milliliter volume of drug or drug dilution to inject into the patient. 2 Electronic-based drug information systems may also provide significant assistance in this regard.…”