Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department

Abstract

Objectives To characterise the incidence and nature of medication errors during paediatric resuscitations. Design A prospective observational study of simulated emergencies. Setting Emergency department of a tertiary paediatric hospital. Participants Teams that included a clinician who commonly leads "real" resuscitations, at least two assisting physicians, and two or three paediatric nurses. Interventions The teams conducted eight mock resuscitations, including ordering medications. Exercises were videotaped and drugs ordered and administered during the resuscitation were recorded. Syringes and drugs prepared during the resuscitation were collected and analysed for concentrations and actual amounts. Main outcome measures Number and type of drug errors. Results Participants gave 125 orders for medications. In 21 (17%) of the orders the exact dose was not specified. Nine dosing errors occurred during the ordering phase. Of these errors, five were intercepted before the drug reached the patient. Four 10-fold errors were identified. In nine (16%) out of 58 syringes analysed, measured drug concentrations showed a deviation of at least 20% from the ordered dose. A large deviation (at least 50%) from the expected dose was found in four (7%) cases. Conclusions Medication errors commonly occur during all stages of paediatric resuscitation. Many errors could be detected only by analysing syringe content, suggesting that such errors may be a major source of morbidity and mortality in resuscitated children.

Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

“…The final error rate (those errors not corrected before reaching the patient) was 26.5%. Unlike the situation in the simulation study by Kozer et al, 7 in the study by Porter et al, a pharmacist was present for 46.9% of the simulations. Multiple logistic regression analysis indicated that the presence of a pharmacist was the only variable that retained significance, indicating a protective effect of pharmacists with an odds ratio of 0.09 (95%CI, 0.01-0.64) for making a medication error.…”

“…Other articles were excluded for the following reasons: 852 were not deemed code related as defined for this review, 4 were review articles, 10 were editorials or letters to the editor, 11 were intervention studies, 9 involved the prehospital setting, 2 were evaluations of errors other than medication errors, and 1 did not quantify the medication errors mentioned. The included studies [4][5][6][7][8][9] are summarized in Table 1. Both authors (A.H.F.…”

“…4,7,9 Although verbal orders in general are discouraged by multiple organizations, including the Joint Commission and the Institute for Safe Medication Practices (ISMP), such orders are often a necessity during code situations. 19,20 Prescribing errors during code-related situations most likely are due to a combination of stress errors, knowledge-deficit errors, incomplete orders, and inaccurate interpretation of verbal orders.…”

Erros de medicação em pediatria

“…Em unidades pediátricas para atendimento de emergência, diferentes estudos apontam que grande parte dos erros acontecem durante o procedimento de reanimação cardiorrespiratória, principalmente em plantões noturnos e aos finais de semana, ocorrendo em aproximadamente 10% de todos os pacientes admitidos nesse setor (16,(35)(36) . 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) .…”

Preparing Drugs for Infusion Via Syringe Pump: A Key Step to Ensure Homogeneous Concentration

“…[12][13][14] Errors often found include confusion between 2 products and poor transcription of the prescription, all exacerbated by stress and fatigue. 15 Calculation errors and dilutions are also cited as contributing factors in failure rates. 16,17 To reduce the incidence of these types of negative interventions, several authors recommend the standardization or even centralization of preparation of drugs to be administered via a syringe pump.…”