Medication Safety Monday – Part 3

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Nearly ten years ago, I undertook an project for my Pharmacy degree, with the title “Minimising Medication Errors for Paediatric Inpatients”. The TGA’s recent alert about Paracetamol dosing in addition to events in the Australian national news  have lead me to consider some of the newer literature in and around the of inpatient medication safety in children. This post is the third in a series of five brief reviews. 

 

Bottom Line:

Resuscitation of a critically ill patient is likely a time of increased risk of medication errors.

Cognitive aids are to be encouraged.

Pharmacists may be helpful at a resuscitation.

Much of the literature we’ve looked at so far has not really taken into account the immediacy of prescribing. Whilst the Silva paper in Part 2 looked at the PICU, and Garfield et al investigated the severity of the errors, I thought we’d take a look at the pointy end of things. That is, when you have a crashing patient in front of you. In this paper, Porter & her California colleagues undertook a prospective observational study of errors in Paediatric Sim training.

Porter E, Barcega B, Kim TY. Analysis of medication errors in simulated pediatric resuscitation by residents. West J Emerg Med. 2014 Jul;15(4):486-90. doi: 10.5811/westjem.2014.2.17922. PMID: 25035756

Who?

49 first- & third-year paediatric residents taking part in a simulated resuscitation of a critically unwell child. About half of the participants were interns.

What?

Investigators assessed the accuracy of verbal orders of medication given during the simulated resuscitation. A medication error was defined as a variability from the recommended dose (references given) by greater than 20%. The investigators also analysed the presence or absence of a clinical pharmacist and the use of cognitive aids.

How?

The Sims were recored on video and reviewed by two investigators with standardised data collection forms. Each variable was analysed separately, as well as a separate multiple logistic regression analysis on significant values. Additional information was obtained from the residents prior to the scenario.

What was found?

In the scenarios, there was a potential medication error rate of ~40% identified with the initial prescribed medication. 65% of the errors were dose related, in 40% there was an unknown dose and 5% gave an inappropriate medication. 65% of the initially prescribed errors were corrected prior to delivery, hence the final medication error rate was 26.5%.

Cognitive aids (code sheet, handheld device, pocket-books, calculators) were used by 12 of the 49 residents. Interns were more likely to use cognitive aids than senior residents, although the number was not significantly different.

Pharmacists were invited to join the Sim settings, and were present at just under half of the scenarios (due to rostering etc); they were more often present in the simulations run by interns than residents. Of the errors corrected prior to drug delivery, pharmacists corrected ~70%. Three errors were not caught prior to administration when a pharmacist was present.

The questionnaires showed that (only) a third of residents had slept more than 8 hours the previous night. In fact, the only metric that showed a statistically significant reduction in medication errors, was the presence of a pharmacist at the resuscitation. The article does not state the total number of errors; all the figures are given as percentages. It’d be good to see some more raw data, including the agents used and a bit more breakdown of the errors.

To conclude, the authors found that the following are associated with a decreased rate of medication error in a simulated training scenario involving a critically ill child: pharmacist presence; getting enough (>8hrs) sleep; being a senior resident; and baseline high confidence.

My interpretation of this articles is that:

Residents need a good night’s sleep – fatigue is a problem, albeit slightly outside the scope of this series.

Resuscitation of a critically ill patient is likely a time of increased risk of medication errors.

Cognitive aids are to be encouraged.

Damian Roland and Dilshad Marikar have both written previously on the risks and innacuracies of doing maths in your head in a critical clinical situation (or any clinical situation). It’s worth noting that incorrectly estimating a patient’s weight can quite easily lead to 20% variability in dosing, the criteria used in this study.

Pharmacists may be helpful at a resuscitation; although not discussed specifically, I wonder if the role of the pharmacist equates well to the question & answer checking system for verbal orders.

 

References:

Marikar D, Varshneya K, Wahid A, Apakama O. Just too many things to remember? A survey of paediatric trainees’ recall of Advanced Paediatric Life Support (APLS) weight estimation formulae. Arch Dis Child. 2013 Nov;98(11):921. doi: 10.1136/archdischild-2013-304360. Epub 2013 Aug 21. Accessed 28 Oct 2014

Roland, D. EM isn’t child’s play when it’s Emergency Maths http://rolobotrambles.com/2014/08/27/em-isnt-childs-play-when-its-emergency-maths/ Published 27 Aug 2014. Accessed 28 Oct 2014.

 

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A Paediatric Trainee based in Queensland, Australia, Henry is passionate about Adolescent Medicine & General Paediatrics, with a strong interest in Medical Education & Clinical Teaching. An admitted nerd & ironman with a penchant for Rubik's Cubes & 'Dad jokes'.

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One Response to "Medication Safety Monday – Part 3"

  1. Dilshad Marikar
    Dilshad Marikar 3 years ago .Reply

    This is an interesting paper, I wished there was some detail in it on the class of drugs that were associated with errors more frequently. My money is on infusions of one kind or another. The most useful sim session I went on recently involved me writing up a dinoprostone infusion and the nurse actually having to make it up, and that was a real eye opener for me

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