Preventing Medical Errors in Pediatric Emergency Medicine

Abstract

A 3-year-old girl received treatment in a pediatric Emergency Department (ED). Nurses in the ED had drawn up saline flush syringes from multiple dose vials of saline to clear her intravenous (IV) line. Apparently, syringes of vecuronium had been prepared for another patient who was treated before the 3-year-old arrived at the hospital. One syringe filled with vecuronium had gone unused and it was somehow mixed with the saline supplies. The syringe was hand labeled similarly to the saline syringes. As a result, a syringe containing vecuronium was used to flush the IV line of the 3-yearold girl. The child quickly became frightened and then flaccid. When all respiratory efforts ceased, she was immediately intubated and ventilated. Personnel identified the error after closer inspection of the syringes. The patient was treated supportively and fortunately suffered no permanent harm. The child's father who was present at the time of the incident reported it to the local press and the event received extensive local media attention. 1 A 5-year-old boy received ketamine for a laceration repair in the ED. The physician ordered 5 mg/kg; the patient received 50 mg/kg due to a ''math error.'' Although the patient experienced no respiratory depression, the physician chose to intubate the child as a precaution. He was discharged from the ED awake and alert 5 hours after receiving the medication. Fortunately, he suffered no long-term sequelae. 2 A 4-year-old boy was given ketamine in the ED for a fracture reduction. The order was written for 1 mg/kg of ketamine; the child received 10 mg/kg of the drug due to inadvertent use of the 100-mg/mL formulation of ketamine instead of the 10-mg/mL formulation. Two minutes after injection of the medication, the child experienced respiratory distress with oxygen desaturation to 65%. Ventilation was assisted for 9 minutes, and was then followed by normal spontaneous respirations. The patient was observed in the ED for 3 hours following receipt of the drug. He was well at discharge and suffered no long-term sequelae from the medication error. 2

Enhancing Safe Medication Use for Pediatric Patients in the Emergency Department

“…7,8 Such reviews provide pharmacists with an opportunity to enhance their leadership role in advocating for safe medication practices within their organizations. Selbst and others 9 identified pharmacist involvement in the emergency department as a strategy for preventing medical errors in pediatric emergency medicine, based on success in inpatient care. Idrees and Clements 5 noted that "Pharmacists are established members of multidisciplinary teams throughout other areas of the hospital.…”

“…9 One example is availability of "ready-to-use" dosage forms appropriate for pediatric use, 10 beginning with high-alert medications and those that may be required in an emergency.…”

Telemedicine Consultations and Medication Errors in Rural Emergency Departments

“…2,5,13 Errors in dosing were the most common type, consistent with previous studies involving children in other acute care settings. [3][4][5][6]8,11,13 These studies attributed dosing errors in children to the chaotic environment in EDs and the lack of sufficient provider training and knowledge in calculating medication doses for children. [3][4][5][6]8,11,13 Our finding of lower physician-related ED medication errors among patients who received telemedicine consultations could be attributed to the specialized training and higher level of experience among the consulting physicians in treating children, which is consistent with other studies evaluating the impact of physician training and experience on patient outcomes.…”

“…1 Patients receiving treatment in emergency departments (EDs) are at particularly high risk for experiencing medication errors due to the acute nature of the presenting illness, the importance of timely administration of therapies, [2][3][4][5][6] the chaotic environment, and the lack of oversight to verify medication orders and administration. 7,8 Particularly among children, the risk of medication errors is magnified because of weight-based drug dosing and limited experience among many health care professionals in pediatric prescribing and pharmacotherapy.…”

Erros de medicação em pediatria

“…Em situações de emergência os erros são atribuídos à necessidade de implementação da terapia medicamentosa em período de tempo extremamente reduzido, à complexidade do atendimento, às diversas interrupções que impedem a continuidade do cuidado, a flutuações na quantidade de pacientes assistidos, ao envolvimento de menor número de profissionais que poderiam interceptar o erro e à dificuldade na utilização da dispensação de medicamentos por dose unitária em tais unidades (37) . Estudo realizado com objetivo de avaliar a incidência e a origem dos erros de medicação entre crianças atendidas em quatro unidades de emergência evidenciou 84 erros nos prontuários dos 182 pacientes selecionados para estudo, Rev Bras Enferm, Brasília 2011 mai-jun; 64(3): 563-9. resultando em taxa de 39% de erros.…”