Pediatric Medication Safety in the Emergency Department

Nurses' perspectives on child-friendly care needs in emergency departments: A qualitative study

BACKGROUND

Children can become anxious when undergoing emergency medical treatment. Therefore, emergency departments should be child friendly. This study explored emergency nurses' perspectives on children's needs during emergency care.

METHOD

This qualitative study employed purposive sampling to recruit 17 emergency nurses from 3 medical centers in northern and central Taiwan. Individual interviews were conducted between January and August 2021. Data were analyzed through qualitative content analysis.

RESULTS

The participants had 2-23 years of experience in caring for children in emergency departments. We identified 208 unique meaning units in the interview data, 79 of which were related to child-friendly emergency care. These were classified into 42 codes across 6 categories and 27 subcategories. The six categories were timely comfort, emotional care, frontline safety, emergency response, human resources support, and treatment efficiency.

CONCLUSION

Emergency nurses have professional competencies, play a crucial role as care providers for children in the emergency department, and ensure the comfort and safety of children seeking treatment. The categories related to child-friendly emergency care identified in this study can serve as a basis for developing child-friendly care emergency guidelines.

Telemedicine vs Telephone Consultations and Medication Prescribing Errors Among Referring Physicians: A Cluster Randomized Crossover Trial

Importance

Critically ill children presenting to emergency departments (EDs) in non-children's hospitals are at high risk for experiencing medical errors, including medication errors. Video telemedicine consultations with pediatric specialists have the potential to reduce the risk of medication errors beyond the current standard of care, telephone consultations.

Objective

To compare the rates of ED physician-related medication errors among critically ill children randomized to receive either video telemedicine or telephone consultations.

Design, Setting, and Participants

This cluster randomized, unbalanced crossover trial was conducted at 15 community EDs in northern California between September 2014 and March 2018. Analyses were conducted from May 2022 to January 2023. Participants included acutely ill children younger than 15 years presenting to a participating ED.

Interventions

Participating EDs were randomized to use video telemedicine or telephone for consultations with pediatric critical care physicians according to 1 of 4 unbalanced (3 telemedicine to 1 telephone) crossover treatment assignment sequences.

Main Outcomes and Measures

Pharmacists reviewed medical records to document physician-related medication errors using a previously validated instrument. Multilevel logistic regression analyses were performed to create models with the medication order as the unit of analysis and adjusting for age, the log-transformed Revised Pediatric Emergency Assessment Tool score, and hospital study period.

Results

A total of 696 patient encounters were included in the trial (mean [SD] age, 4.2 [4.6] years; median [IQR] age, 2.1 [0.5-2.1] years; 304 female [43.7%]), with 537 patient encounters (77.2%) assigned to video telemedicine and 159 patient encounters (22.8%) assigned to telephone. At least 1 physician-related medication error occurred for 87 patients (12.5%), including 20 of 159 patients (12.6%) in the telephone cohort and 67 of 537 patients (12.5%) in the telemedicine cohort. Of the 2414 medication orders, errors occurred in 124 cases (5.1%), including 26 of 513 orders (5.1%) in the telephone cohort and 98 of 1901 orders (5.2%) in the telemedicine cohort. In the multivariable analysis, the adjusted odds ratio of experiencing a medication error among those assigned to telemedicine was 0.86 (95% CI, 0.49-1.52; P = .61).

Conclusions and Relevance

This cluster randomized crossover trial found no statistically significant differences in physician-related medication errors between critically ill children assigned to receive telephone consultations vs video telemedicine consultations.

Trial Registration

ClinicalTrials.gov Identifier: NCT02877810.

Patient-Safety Culture among Emergency and Critical Care Nurses in a Maternal and Child Department

INTRODUCTION

The quality of healthcare has multiple dimensions, but the issue of patient safety stands out due to the impact it has on health outcomes, particularly on the achievement of the Sustainable Development Goals (SDGs), expressly SDG3. In the services that we propose to study, the patient-safety culture had never been evaluated.

AIM

To evaluate nurses' perceptions of the patient-safety culture in the Emergency and Critical Care Services of the Maternal and Child Department of a University Hospital and to identify strengths, vulnerabilities, and opportunities for improvement.

METHODS

This an exploratory, cross-sectional study with a quantitative approach, using the Hospital Survey on Patient Safety Culture as an instrument for data collection. The population were all nurses working in the emergency and critical care services of the maternal and child-health department, constituted, at the time of writing, by 184 nurses, with a response rate of 45.7%.

RESULTS

Applying the guidelines from the Agency for Healthcare Research and Quality (AHRQ), only teamwork within units had a score greater than 75%. For this reason, it is considered the strength (fortress) in the study. The lowest-rated were non-punitive responses to errors and open communication.

CONCLUSION

The overall average percentage score is below the benchmark of the AHRQ, indicating that issue of patient safety is not considered a high priority, or that the best strategies to make it visible have not yet been found. One of the important implications of this study is the opportunity to carry out a deep reflection, within the organization, that allows the development of a non-punitive work environment that is open to dialogue, and that allows the provision of safe nursing care.

Small patients, big challenges: navigating pediatric drug manipulations to prevent medication errors - a comprehensive review

INTRODUCTION

Medication errors during drug manipulations in pediatric care pose significant challenges to patient safety and optimal medication management. Epidemiological studies have revealed a high prevalenceof medication errors throughout the medication process. Due to the lack of age-appropriate dosage forms, medication manipulation is common in pediatric drug administration. The consequences of these manipulations on drug efficacy and safety could be devastating, highlighting the need for evidence-based guidelines and standardized compounding practices.

AREAS COVERED

This review focuses on examining medication errors in pediatric care and delving into the manipulation of medicinal products.

EXPERT OPINION

The observed prevalence of medication errors and manipulations underscores the importance of addressing these issues to enhance patient safety and improve medication outcomes in pediatric care. Overall, the development of age-appropriate formulations and the dissemination of comprehensive clinical guidelines are essential steps toward improving medication safety and minimizing manipulations in pediatric healthcare settings.

Antibiotic clinical decision support for pneumonia in the ED: A randomized trial

BACKGROUND

Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED).

OBJECTIVE

To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED.

DESIGN

Pragmatic randomized clinical trial.

SETTING AND PARTICIPANTS

Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States.

INTERVENTION

CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines.

MAIN OUTCOME AND MEASURES

The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits.

RESULTS

1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes.

CONCLUSIONS

Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

How safe are paediatric emergency departments? A national prospective cohort study

BACKGROUND

Despite the high number of children treated in emergency departments, patient safety risks in this setting are not well quantified. Our objective was to estimate the risk and type of adverse events, as well as their preventability and severity, for children treated in a paediatric emergency department.

METHODS

Our prospective, multicentre cohort study enrolled children presenting for care during one of 168 8-hour study shifts across nine paediatric emergency departments. Our primary outcome was an adverse event within 21 days of enrolment which was related to care provided at the enrolment visit. We identified 'flagged outcomes' (such as hospital visits, worsening symptoms) through structured telephone interviews with patients and families over the 21 days following enrolment. We screened admitted patients' health records with a validated trigger tool. For patients with flags or triggers, three reviewers independently determined whether an adverse event occurred.

RESULTS

We enrolled 6376 children; 6015 (94%) had follow-up data. Enrolled children had a median age of 4.3 years (IQR 1.6-9.8 years). One hundred and seventy-nine children (3.0%, 95% CI 2.6% to 3.5%) had at least one adverse event. There were 187 adverse events in total; 143 (76.5%, 95% CI 68.9% to 82.7%) were deemed preventable. Management (n=98, 52.4%) and diagnostic issues (n=36, 19.3%) were the most common types of adverse events. Seventy-nine (42.2%) events resulted in a return emergency department visit; 24 (12.8%) resulted in hospital admission; and 3 (1.6%) resulted in transfer to a critical care unit.

CONCLUSION

In this large-scale study, 1 in 33 children treated in a paediatric emergency department experienced an adverse event related to the care they received there. The majority of events were preventable; most were related to management and diagnostic issues. Specific patient populations were at higher risk of adverse events. We identify opportunities for improvement in care.

Weighty Matters: A Real-World Comparison of the Handtevy and Broselow Methods of Prehospital Weight Estimation

INTRODUCTION

The majority of pediatric medications are dosed according to weight and therefore accurate weight assessment is essential. However, this can be difficult in the unpredictable and peripatetic prehospital care setting, and medication errors are common. The Handtevy method and the Broselow tape are two systems designed to guide Emergency Medical Services (EMS) providers in both pediatric patient weight estimation and medication dosing. The accuracy of the Handtevy method of weight estimation as practiced in the field by EMS has not been previously examined.

STUDY OBJECTIVE

The primary objective of this study was to examine the field performance of the Handtevy method and the Broselow tape with respect to prehospital patient weight estimation.

METHODS

This was a retrospective chart review of trauma and non-trauma patients transported by EMS to the emergency department (ED) of a quaternary care children's hospital from January 1, 2021 through June 30, 2021. Demographic data, ED visit information, prehospital weight estimation, and medication dosing were collected and analyzed. Scale-based weight from the ED was used as the standard for comparison.

RESULTS

A total of 509 patients <13 years of age were included in this study. The EMS providers using the Broselow method estimated patient weight to within +/-10% of ED scale weight in 51.3% of patients. When using the Handtevy method, the EMS providers estimated patient weight to within +/-10% of ED scale weight in 43.7% of patients. When comparing the Handtevy versus Broselow method of prehospital weight estimation, there was no significant association between method and categorized weight discrepancy (over, under, or accurate estimates - defined as within 10% of ED scale weight; P = .25) or percent weight discrepancy (P = .75). On average, prehospital weight estimation was 6.33% lower than ED weight with use of the Handtevy method and 6.94% lower with use of the Broselow method.

CONCLUSION

This study demonstrated no statistically significant difference between the use of the Handtevy or Broselow methods with respect to prehospital weight estimation. While further research is necessary, these results suggest similar field performance of the Broselow and Handtevy methods.

Decision-Making in the Pediatric Emergency Department-A Survey of Guidance Strategies among Residents

(1) Introduction: Working in an emergency department requires fast and straightforward decisions. Therefore, decision guidance represents an essential tool for successful patient-centered care. Beyond the residents' own knowledge and experience, printed books have been the primary source of information in the past. The aim of this study was to discover which strategies current residents use the most and to identify alternative quick reference strategies in the digital age. (2) Materials and Methods: This study analyzed the responses of a short questionnaire directed at 41 residents in a single pediatric emergency department (32 pediatric and 9 pediatric surgery residents) over a period of one month. (3) Results: Thirty-three (80.5%) residents answered the entire questionnaire. Strikingly, responses indicated that printed books are still pivotal in guiding decision-making. In addition, the acquisition of information via computers or smartphones plays an increasing role. However, the opinion and council of the attending physician is still of great value to the residents and is not to be underestimated. Overall, most of the residents would prefer to have access to a specially designed smartphone application. (4) Conclusions: Certainty and validity are essential in decision-making in a pediatric emergency department. Although printed books and attending physicians are still considered as reliable sources of information, internet-based information plays an increasing role. In order to provide the best up-to-date and most recent information, a validated and consistently updated smartphone application could be a useful option.

Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study

Purpose

This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting.

Patients and Methods

We performed a 10-year retrospective study (January 2011–December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome.

Results

In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour–14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs.

Conclusion

Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.

Reducing Pediatric Emergency Department Prescription Errors

BACKGROUND

Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines.

METHODS

From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing.

RESULTS

Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased.

CONCLUSION

QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.

Medication Errors in Pediatrics: Proposals to Improve the Quality and Safety of Care Through Clinical Risk Management

Medication errors represent one of the most common causes of adverse events in pediatrics and are widely reported in the literature. Despite the awareness that children are at increased risk for medication errors, little is known about the real incidence of the phenomenon. Most studies have focused on prescription, although medication errors also include transcription, dispensing, dosage, administration, and certification errors. Known risk factors for therapeutic errors include parenteral infusions, oral fluid administration, and tablet splitting, as well as the off-label use of drugs with dosages taken from adult literature. Emergency Departments and Intensive Care Units constitute the care areas mainly affected by the phenomenon in the hospital setting. The present paper aims to identify the risk profiles in pediatric therapy to outline adequate preventive strategies. Precisely, through the analysis of the available evidence, solutions such as standardization of recommended doses for children, electronic prescribing, targeted training of healthcare professionals, and implementation of reporting systems will be indicated for the prevention of medication errors.

The Study of Drug-Related Problems in Pediatric Inpatients Utilizing Antibiotics in Universitas Sumatera Utara Hospital Medan, Indonesia

BACKGROUND: Drug-related problems (DRPs) and errors occur frequently in general health and pediatric care due to several reasons. AIM: This study aims to determine the DRPs incidence in pediatric inpatients utilizing antibiotics in Universitas Sumatera Utara Hospital, Medan, Indonesia. MATERIALS AND METHODS: It was carried out in May–July 2019 using a retrospective cross-sectional method and the data obtained from June to December 2018. RESULTS: In the aforementioned hospital, the medical records of patients were 575 among which 135 (23.47%) met the inclusion criteria and the males, 84 (62.22%) were higher than females. Furthermore, majority of them, 55 (40.74%) were 5–11 years old, and 86 (63.70%) had a maximum stay length of ≥5 days. There were 73 DRPs events in 37 patients, namely, 46 (63.01%) low doses, 22 (30.14%) overdoses, 2 (2.74%) side effects of drugs, and 3 (4.11%) drug interactions. The most experienced antibiotic DRPs were in cefotaxime 14 (19.17%) and the most diagnosed was in appendicitis 14 (10.37%) utilization. CONCLUSION: There were antibiotic DRPs in pediatric inpatients in Universitas Sumatera Utara Hospital, Medan.

Preventing Home Medication Administration Errors

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Pediatric Emergency Department Interventions of Pharmacy Residents

OBJECTIVE

We sought to assess the frequency and types of interventions performed by pharmacy residents in a pediatric emergency department (ED).

METHODS

The study was conducted in an academic ED with 77,000 annual visits, of which 17% are pediatric. Six pharmacy residents completed a total of 9 two-week rotations in the pediatric ED as part of their pharmacy residency programs from February 2016 to December 2018. Pharmacy residents recorded pharmacy intervention data in real time. We quantified the number and type of interventions and time spent making the interventions.

RESULTS

Of 1608 pediatric patients present during the ED shifts when pharmacy residents were on service, pharmacy residents intervened on 294 patients (18.3%). A total of 400 activities and interventions were recorded. The majority (72%) of patients required 1 intervention, whereas the remaining 28% had 2 or more interventions documented. The median time spent per patient was 15 minutes (interquartile range, 10-20 minutes). Pharmacy residents were most commonly involved with medication selection and dosing.

CONCLUSIONS

The presence of a dedicated pharmacy team member in the pediatric area of the ED allows for a high level of involvement and interaction with other members of the health care team primarily through providing recommendations regarding medication selection, dosing, optimization, and answering drug information and medication administration questions.

Pharmacists' Approach to Optimise Safe Medication Use in Paediatric Patients

Paediatric patients are unique, yet challenging patients to care for by pharmacists. Paediatric medicine use requires special consideration. Pharmacists play an important role in educating and counselling patients, carers, and healthcare workers. Further, pharmacists have the necessary knowledge and skills to optimise safe medicine use in paediatric patients. This article provides basic principles for safe practices in paediatric medicine by following the nine rights of medication administration.

Cross-sectional study on the drug utilization and evaluation indicator of antibiotics used in pediatric population

Background

The lack of medication standards is a serious problem in paediatrics mainly because of age-related differences in organ development and physiological functions in children. Consequently, dosage measurement becomes inaccurate. For this reason, methods for evaluating and monitoring rational paediatric medications should be developed. Drug use indicators, such as those similar to the drug utilisation index (DUI) based on the Anatomical Therapeutic Chemical/Defined Daily Dose (DDD) and widely used for the assessment of appropriate dosage in adults, should be explored in terms of their applicability to children.

Methods

A total of 5,538 prescriptions of antibiotics selected from a general teaching hospital were included. Drug, dose, frequency and treatment duration were obtained from each prescription. The prescription daily dose (PDD) of each antibiotic drug was calculated as the average of the daily doses. Underdose and overdose were determined in terms of the PDD/DDD ratio for each prescription. Children’s DUI (cDUI) was explored in terms of the appropriate dosage for children as follows: the meaning of children’s DDD (cDDD) and the evaluation of paediatric drug dosage.

Results

The top five antibiotics and their utilisation rates were as follows: cefmetazole sodium injection (18.47 %), erythromycin lactobionate injection (15.07 %), amoxicillin/clavulanate potassium injection (10.72 %), ceftriaxone sodium injection (9.50 %) and azithromycin dry suspension (8.02 %). The ratio of cDUI and PDD/cDDD was mostly not close to 1.

Conclusions

The establishment of a cDUI system is an effective means of paediatric dosage evaluation. In addition to DDDs, cDUI and PDD/cDDD should be used to analyse the utilisation of antibiotics in children.

Impact of a Mobile App on Paramedics' Perceived and Physiologic Stress Response During Simulated Prehospital Pediatric Cardiopulmonary Resuscitation: Study Nested Within a Multicenter Randomized Controlled Trial

BACKGROUND

Out-of-hospital cardiac arrests (OHCAs) are stressful, high-stake events that are associated with low survival rates. Acute stress experienced in this situation is associated with lower cardiopulmonary resuscitation performance in calculating drug dosages by emergency medical services. Children are particularly vulnerable to such errors. To date, no app has been validated to specifically support emergency drug preparation by paramedics through reducing the stress level of this procedure and medication errors.

OBJECTIVE

This study aims to determine the effectiveness of an evidence-based mobile app compared with that of the conventional preparation methods in reducing acute stress in paramedics at the psychological and physiological levels while safely preparing emergency drugs during simulated pediatric OHCA scenarios.

METHODS

In a parent, multicenter, randomized controlled trial of 14 emergency medical services, perceived and physiologic stress of advanced paramedics with drug preparation autonomy was assessed during a 20-minute, standardized, fully video-recorded, and highly realistic pediatric OHCA scenario in an 18-month-old child. The primary outcome was participants' self-reported psychological stress perceived during sequential preparations of 4 intravenous emergency drugs (epinephrine, midazolam, 10% dextrose, and sodium bicarbonate) with the support of the PedAMINES (Pediatric Accurate Medication in Emergency Situations) app designed to help pediatric drug preparation (intervention) or conventional methods (control). The State-Trait Anxiety Inventory and Visual Analog Scale questionnaires were used to measure perceived stress. The secondary outcome was physiologic stress, measured by a single continuous measurement of the participants' heart rate with optical photoplethysmography.

RESULTS

From September 3, 2019, to January 21, 2020, 150 advanced paramedics underwent randomization. A total of 74 participants were assigned to the mobile app (intervention group), and 76 did not use the app (control group). A total of 600 drug doses were prepared. Higher State-Trait Anxiety Inventory-perceived stress increase from baseline was observed during the scenario using the conventional methods (mean 35.4, SD 8.2 to mean 49.8, SD 13.2; a 41.3%, 35.0 increase) than when using the app (mean 36.1, SD 8.1 to mean 39.0, SD 8.4; a 12.3%, 29.0 increase). This revealed a 30.1% (95% CI 20.5%-39.8%; P<.001) lower relative change in stress response in participants who used the app. On the Visual Analog Scale questionnaire, participants in the control group reported a higher increase in stress at the peak of the scenario (mean 7.1, SD 1.8 vs mean 6.4, SD 1.9; difference: -0.8, 95% CI -1.3 to -0.2; P=.005). Increase in heart rate during the scenario and over the 4 drugs was not different between the 2 groups.

CONCLUSIONS

Compared with the conventional method, dedicated mobile apps can reduce acute perceived stress during the preparation of emergency drugs in the prehospital setting during critical situations. These findings can help advance the development and evaluation of mobile apps for OHCA management and should be encouraged.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03921346; https://clinicaltrials.gov/ct2/show/NCT03921346.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3726-4.

Improving pediatric pharmacy services in a primarily adult emergency department

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

The American Society of Health-System Pharmacists (ASHP) and Pediatric Pharmacy Advocacy Group (PPAG) guidelines for providing pediatric pharmacy services in hospitals and health systems can be used to improve medication safety wherever pediatric patients receive care, including in the emergency department (ED). The purpose of this initiative was to improve compliance with these guidelines in a primarily adult ED.

Methods

This quality improvement initiative was conducted in a level 1 trauma center ED between October 2019 and March 2020. The ASHP-PPAG guidelines were used to create practice elements applicable to the ED. An initial compliance assessment defined elements as noncompliant, partially compliant, fully compliant, or not applicable. Investigators identified interventions to improve compliance for noncompliant or partially compliant elements and then reassessed compliance following implementation. Data were expressed using descriptive statistics. This initiative was exempt from institutional review board approval.

Results

Ninety-three ED practice elements were identified within the 9 standards of the ASHP-PPAG guidelines. At the initial compliance assessment, the majority (59.8%) of practice elements were fully compliant; however, various service gaps were identified in 8 of the standards, and 16 interventions were implemented to improve compliance. At the final compliance assessment, there was a 19.5% increase in full compliance. Barriers to achieving full compliance included technology restrictions, time constraints, financial limitations, and influences external to pharmacy.

Conclusion

This quality improvement initiative demonstrated that the ASHP-PPAG guidelines can be used to improve ED pediatric pharmacy services in a primarily adult institution. The initiative may serve as an example for other hospitals to improve compliance with the guidelines.

Implementing an emergency department pharmacy service and its effect on medication safety

OBJECTIVES

This service innovation project examined the effect an Emergency Department (ED) pharmacy service had on medication-related safety markers.

METHODS

A pre-test/post-test design captured medication-related safety markers on admission data at ward level after patients had been seen in the ED. The markers were, medication omitted, incorrect medicines prescribed and the number of incorrect doses or frequency of doses.

KEY FINDINGS

All three safety markers saw reductions. Mean (SD) medications omitted were reduced from 2.19 (±3.01) to 0.48 (±1.3), incorrect medication from 0.35 (±1.11) to 0.08 (±0.36) and the number of incorrect doses or frequency of doses from 0.38 (±0.69) to 0.13 (±0.38) per patient. All differences were statistically significant (P = 0.00).

CONCLUSIONS

The service reduced medication error and the findings allowed a permanent pharmacy service to be introduced.

Polypharmacy, Dosing Trends and Drug-Drug Interaction Patterns Following High-Level Limb Amputation Surgery

OBJECTIVE

To examine peri-operative medication patterns, surrounding major amputation surgeries.

DESIGN

Retrospective chart review of 216 cases of major amputations (transfemoral, hip disarticulation, hemipelvectomy, forequarter) at an academic hospital, examining medications, dosing changes and drug-drug interaction warnings pre- and post-operatively.

RESULTS

Medications increased in 76.9% (166/216), remained the same in 10.6% (23/216), and decreased in 12.5% (27/216) of cases. Average number of medications was 7 pre-operatively and 10 post-operatively. In 189 cases with pre-operative medications present, post-operative dosing remained the same for 74.3%, increased for 9.2%, decreased for 7.6% and was unknown for 8.9% of medications. Increases in each of type C ("monitor therapy"), D ("consider therapy modification) and X ("avoid combination") drug-drug interaction warnings were seen respectively in 59.7%, 62.0% and 5.1% of cases.

CONCLUSION

Polypharmacy is involved pre-operatively and increased post-operatively in most cases of major limb amputation, with agent dosing remaining the same or increased in the majority of cases. Drug-drug interaction warnings also increase. These occur at a time of abrupt changes to the body's size, compartments, and physiologic responses. More research and clinical attention are warranted given anticipated changes in pharmacokinetics and pharmacodynamics.

Prescribing errors and associated factors in discharge prescriptions in the emergency department: A prospective cross-sectional study

OBJECTIVES

Evidence regarding the prevalence of medication prescribing errors (PEs) and potential factors that increase PEs among patients treated in the emergency department (ED) are limited. This study aimed to explore the prevalence and nature of PEs in discharge prescriptions in the ED and identify potential risk factors associated with PEs.

METHODS

This was a prospective observational cross-sectional study in an ambulatory ED in a tertiary teaching hospital. Data were collected for six months using a customized reporting tool. All patients discharged from ED with a discharged prescription within the study period were enrolled in this study.

RESULTS

About 13.5% (n = 68) of the 504 prescriptions reviewed (for 504 patients) had at least one error. Main PEs encountered were wrong dose (23.2%), wrong frequency (20.7%), and wrong strength errors (14.6%). About 36.8% of identified PEs were related to pediatric prescriptions, followed by the acute care emergency unit (26.5%) and the triage emergency unit (20.6%). The main leading human-related causes associated with PEs were lack of knowledge (40.9%) followed by an improper selection from a computer operator list (31.8%). The leading contributing systems related factors were pre-printed medication orders (50%), lack of training (31.5%), noise level (13.0%), and frequent interruption of prescriber and distraction (11.1%). Prescribers' involved with the identified errors were resident physicians (39.4%), specialists (30.3%), and (24.4%) were made by general practitioners. Physicians rejected around 12% of the pharmacist-raised recommendations related to the identified PEs as per their clinical judgment.

CONCLUSION

PEs in ED setting are common, and multiple human and systems-related factors may contribute to the development of PEs. Further training to residents and proper communication between the healthcare professionals may reduce the risk of PEs in ED.

Got a Pen for Allergen Immunotherapy? Lessons from Near-Fatal Anaphylaxis with Pulmonary Edema

On our pediatric intensive care unit, we successfully treated a 10-year-old boy with severe pulmonary edema due to anaphylaxis after his last injection of a 3-year course of allergen immunotherapy (AIT). In view of the severity of the adverse event, we initiated a case analysis with all involved medical professionals. The evaluation revealed delayed administration of epinephrine due to dosing uncertainty and underestimation of severity. Consequently, all involved institutions established epinephrine auto-injectors (EAIs) in their emergency equipment. We suggest providing EAIs in every practice conducting AIT, as well as in pediatric emergency rooms and ambulances. We would like to remind readers of the risk of anaphylaxis, even on the last day of AIT.

International consensus validation of the POPI tool (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions) to identify inappropriate prescribing in pediatrics

INTRODUCTION

While drug prescription should be based on established recommendations stemming from clinical trials but in pediatrics, many drugs are used without marketing authorization. Consequently recommendations are often based on clinical experience and the risk of inappropriate prescription (IP) is high. A tool for detecting IP in pediatrics-called POPI (Pediatrics: Omission of Prescriptions and Inappropriate prescriptions)-has been developed in France. However the relevance of its use at an international level is not known. Our aim has been to adapt POPI for a worldwide use.

MATERIAL AND METHOD

A two-round Delphi online questionnaire was completed and validated by international experts to identify consensual items. They were asked to rate the validity of each items taking into account the recommendations and practices in their countries. Only propositions obtaining a median score in the upper tertile with an agreement of more than 75% of the panel-for the first round-and 85%-for the second round-were retained.

RESULTS

Our panel included 11 pharmacists (55%) and 9 physicians (45%). The panelists came from 12 different countries: England, Belgium, Brazil, Canada, China, Ivory Coast, Ireland, Malaysia, Portugal, Switzerland, Turkey and Vietnam. At the end of the first round, of the 105 items of the original POPI tool, 80 items were retained including 16 items reworded and 25 items were deleted. In the second round, 14 experts participated in the study. This final international POPI tool is composed of 73 IP and omissions of prescriptions in the fields of neuropsychiatry, dermatology, infectiology, pneumology, gastroenterology, pain and fever.

DISCUSSION AND CONCLUSION

This study highlights international consensus on prescription practice in pediatrics. The use of this tool in everyday practice could reduce the risk of inappropriate prescription. The impact of the diffusion of POPI tool will be assessed in a prospective multicentric study.

Pediatric medication safety considerations for pharmacists in an adult hospital setting

PURPOSE

Risks and vulnerabilities of the medication-use process in nonpediatric institutions that also serve pediatric patients are reviewed, and guidance on risk mitigation strategies is provided.

SUMMARY

There are many risks and vulnerabilities in the medication-use process as it relates to pharmacotherapy for pediatric patients admitted to adult institutions. Mitigation of these risks is critical and should encompass various available resources and strategies. Special emphasis should be placed on use of technology to improve overall safety. Available literature recommends optimization of technology and resource use, institutional support for pediatric pharmacists' involvement in managing pediatric medication use, and provision of early exposure to pediatric patients in pharmacist training programs as additional methods of mitigating risks associated with pediatric medication use in adult institutions. Adult hospitals that provide care for pediatric patients should assess their processes in order to identify hospital-specific interventions to promote pediatric medication safety.

CONCLUSION

Pediatric medication safety frameworks in U.S. adult institutions vary widely. Treating pediatric patients involves risks in all areas of the medication-use process. Optimizing technology, utilizing external resources, supporting a pediatric pharmacist, and providing early-career exposure to pediatric patients are methods to mitigate risks in institutions that primarily serve adult patients.

Drugs Used to Treat Pediatric Emergencies

This clinical report is a revision of "Preparing for Pediatric Emergencies: Drugs to Consider." It updates the list, indications, and dosages of medications used to treat pediatric emergencies in the prehospital, pediatric clinic, and emergency department settings. Although it is not an all-inclusive list of medications that may be used in all emergencies, this resource will be helpful when treating a vast majority of pediatric medical emergencies. Dosage recommendations are consistent with current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and American Heart Association resuscitation guidelines.

Lessons from the Established Status Epilepticus Treatment Trial

Convulsive status epilepticus (SE) is a relatively common emergency condition affecting individuals of all ages. The primary goal of treatment is prompt termination of seizures. Where first-line treatment with benzodiazepine has failed to achieve this, a condition known as established SE (ESE), there is uncertainty about which agent to use next. The Established Status Epilepticus Treatment Trial (ESETT) is a 3-arm (valproate (VPA), fosphenytoin (FOS), levetiracetam (LEV)), phase III, double-blind randomized comparative effectiveness study in patients aged 2 years and above with established convulsive SE. Enrollment was completed in January 2019, and the results are expected later this year. We discuss lessons learnt during the conduct of the study in relation to the following: ethical considerations; trial design and practical implementation in emergency settings, including pediatric and adult populations; quality assurance; and outcome determination where treating emergency clinicians may lack specialist expertise. We consider that the ESETT is already informing both clinical practice and future trial design. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

The Effect of Smartphone-Based Application Learning on the Nursing Students' Performance in Preventing Medication Errors in the Pediatric Units

Medication errors (MEs) are potentially harmful patient safety events in all age groups. MEs are particularly hazardous in the pediatric population, especially with patients who require special attention due to the high incidence and severity of disease. This study aimed to determine the effect of a smartphone messenger application on nursing students' learning regarding the prevention of MEs in pediatric patients.

METHODS

We performed this quasi-experimental study with 80 nursing students who were randomly divided into intervention and control groups. We collected the data using a researcher-made checklist. We conducted learning through Telegram, a smartphone messenger application (app), for 3 weeks. We analyzed data using SPSS version 16.0 by utilizing descriptive and inferential statistics, and P < 0.05 was considered to be significant.

RESULTS

The mean age of the students was 23.5 ± 2.9 years. The majority of mistakes related to MEs in the control groups included the lack of proper control of the following: high risk medication administration, medication incompatibility interactions, medication administration card, medication dose calculations, adverse drug event recognition, pharmaceutical name recognition during drug selection, aseptic and sterile technique adherence, microbore IV tubing flush practices, IV drip rate adjustment, and medication administration schedules. The mean scores of students' performance were significantly different in the knowledge of preventing MEs between the 2 groups. (P = 0.022).

CONCLUSIONS

Smartphone learning with the Telegram messenger app improves nursing student knowledge regarding the prevention of MEs in pediatric patients. We recommend that this form of learning be used in nursing schools to prevent errors related to medication ordering, dosing, and administration.

A systems-centred approach to reducing medication error: Should pre-hospital providers and emergency departments dose children by age during resuscitation?

The high-risk, high-stress and high-stakes environment of out-of-hospital or emergency department paediatric resuscitation is prone to human error, and medication errors are common. This could be contributing to the difference in survival rate of resuscitation in the out-of-hospital versus inpatient setting. Medication for children during resuscitation requires estimation of the child's weight and calculation of the corresponding drug dose. Whilst both of these steps can lead to error, calculation errors (including 10-fold errors) are much more common and harmful than weight errors. Previous solutions aim to optimise each stage of the medication dosing process. Currently, Australian guidelines suggest using the highly inaccurate original advanced paediatric life support formula, weight = 2 × (age + 4), to dose medications in these settings. This means age is converted to weight, which is then converted to dose. There is no evidence that this is causing harm to patients. Therefore, it could be suggested that age could safely be converted straight to dose according to preset doses. This eliminates the need for any weight estimation or dose calculation, thus reducing the potential for error and harm.

Pediatric Antibiotic Pack Size Compliance With the Dosage Regimen: A Descriptive Study

BACKGROUND

The unavailability of appropriate pediatric drug pack size is a global issue. Antibiotics are the lifesaving and most frequently prescribed therapeutic agents given to pediatrics. The objective of this study was to assess the compliance of pediatric antibiotic pack size with the standard dosage regimen.

METHODS

A descriptive study design was employed. Data were collected from a community pharmacy in Bahawalpur, Pakistan, between August 1, 2017, and September 30, 2017. Five most commonly prescribed antibiotics were selected and calculations were made to check the appropriateness of packaging size by comparing the quantity of product in the available pack with the dosage regimen recommended by the British National Formulary for Children (BNFC).

RESULTS

Only 16 clarithromycin, 9 amoxicillin, 1 cefotaxime, and 1 metronidazole packaging sizes were sufficient to meet the dosage regimen for treatment. None of the available pack sizes for gentamicin matched the recommended duration of treatment. The study findings revealed that the available pack sizes either had leftover or a shortfall of antibiotic formulation. Highly inappropriate dosage forms (containing either excess and less quantity) of antibiotics were intravenous infusions and oral suspensions.

CONCLUSION

The study concluded that the packaging sizes of antibiotics failed to supply the recommended dosage regimen to pediatrics for common indications. This may contribute to development of antibiotic resistance among pediatric patients. Health policy makers should devise strict rules and regulations to ensure the availability of child-specific antibiotic pack sizes.