Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study

Abstract

Background: Multi-institutional, international practice variation of pediatric anaphylaxis management by healthcare providers has not been reported.Objective: Characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. Methods:A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 healthcare institutions in six countries. The on-duty healthcare team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected.Results: Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15/37) of institutions. Teams used a cognitive aid for medication dosing 41% (15/37) of the time and 32% (12/37) for preparation. Epinephrine auto injectors (EAIs) were not available in 54% (20/37) of institutions and were used in only 14% (5/37) simulations. Median time to epinephrine administration was 95 seconds (IQR 77, 252) for EAI and 263 seconds (IQR 146, 407.5) for manually prepared epinephrine (p=.12). At least one medication error occurred in 68% (25/37) of simulations. Prior nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (p=.04) and administration (p=.01) errors.Latent safety threats (LSTs) were reported by 30% (11/37) of institutions, more than half of these (6/11) involved a cognitive aid. Conclusion and Relevance:A multicenter, international study of simulated pediatric anaphylaxis reveals: 1) variation in management between institutions in usage of protocols,

Update on food allergy

“…70 When prescribed, AAI are only carried at all times by half of the patients 71 and mistakes in use are frequent among both patients 72 and medical staff. 73 Meeting the needs of both food-allergic children undergoing immunotherapy and those continuing strict avoidance in the same environment, for example school or household with two allergic siblings managed differently, is an arising challenge.…”

Anaphylaxis Refractory to intramuscular adrenaline during in‐hospital food challenges: A case series and proposed management

“…[12][13][14] Despite this, adrenaline remains significantly underused, both in the community, 15 but also in hospital 16 and even in simulated scenarios errors frequently occur. 17 There are, unsurprisingly,…”

“…National and international guidelines recommend the administration of intramuscular adrenaline for initial management of anaphylaxis 12‐14 . Despite this, adrenaline remains significantly underused, both in the community, 15 but also in hospital 16 and even in simulated scenarios errors frequently occur 17 . There are, unsurprisingly, no randomized controlled on the use of adrenaline for anaphylaxis, and recommendations are based on observational data, consensus opinion and pharmacological effect 14,18,19 .…”

Recent Advances in Simulation for Pediatric Critical Care Medicine

“…The benefits of in situ simulation include greater access to providers, enhanced realism, as well as direct parallels and responses to patient care incidents, e.g., just-in-time training [49]. Finally, in situ simulation can allow for systems-based issues and latent safety threats to be discovered and addressed without harm to real patients [50,51]. In situ simulation may also be made mobile with a simple cart, such as with rolling refreshers for CPR [52,53].…”

“…Simulation provides the opportunity to probe a system for vulnerabilities and immediately debrief participants, thus allowing for learning from both success and failure while maintaining psychological safety. A standardized scenario of pediatric anaphylaxis performed in 28 international hospitals identified a high medication error rate, and the postevent debriefings revealed a common LST across institutions related to decision support aids [ 51 ]. Learning opportunities from these system-focused simulations can be maximized by using a specific debriefing framework such as PEARLS for system integration [ 16 ] which is based on Systems Engineering Initiative for Patient Safety (SEIPS) 2.0, a human-factors model of patient safety and the healthcare system [ 93 ].…”