Davis, T. Anaphylaxis and dosing errors, Don't Forget the Bubbles, 2013. Available at:
Medication errors are a particular area of interest for me, so this paper caught my eye….here’s my summary of it.
It’s a paper by Benkelfat et al and is published in the September 2013 issue of the Journal of Emergency Medicine.
Benkelfat R, Gouin S, Larose G, Bailey B. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013 Sep;45(3):419-25.
It looked at using standard order forms to reduce medication errors when managing anaphylaxis in paediatric emergency.
What’s the need for the study?
It may seem surprising, but most doctors do not know the correct dose of adrenaline (epinephrine) to give in the management of anaphylaxis.
Tain and Rubython (2007) showed, in a New Zealand study, that only 20% of doctors actually knew the right dose and route of administration of adrenaline for anaphylaxis. And Drost and Narayan (2010) found that only 15% of UK doctors would give adrenaline as recommended by the UK resuscitation guidelines. These studies were all in adults, and one would expect that in children there would be even more error due to weight variation and low frequency of presentation.
We need to be able to treat anaphylaxis quickly, safely and optimally, as patients can deteriorate rapidly and die from this. And an overdose of adrenaline comes with its own set of side effects.
What was the intervention?
The authors introduced a standard order form (SOF) which was given to doctors when prescribing medications for anaphylaxis (in their Paediatric Emergency Department in Canada).
They then looked at the frequency of medication errors before introducing the SOF and after introducing the SOF.
How did they find the patients?
This was done retrospectively through searching for patients coded with anaphylaxis or anaphylactic shock in their ED database. The notes were then cross-checked with the National Institute of Allergy and Infectious Disease diagnostic criteria for anaphylaxis to make sure the patients did actually have anaphylaxis.
How did they decide what constituted an error?
Incorrect medication dosages (10% and 25% margin of error for doses); wrong drug administration; and a delay in administration (15 min delay for adrenaline, 30 min delay for other drugs).
How many patients were included?
96 patients were included – 31 in the Pre-SOF group and 65 in the Post-SOF group. In the Post-SOF group 30 patients were SOF negative – this means that even though SOF had been introduced in the department, the SOF was not used for that patient.
What did they find?
A whopping 60% of medication charts contained at least one medication error (59% post-SOF).
The number of dosage errors did reduce significantly when the SOF was used (this was the same using either the 10% error margin or the 25% one).
Perhaps most importantly for our learning, the correct adrenaline doses for managing anaphylaxis in paediatric emergency are…
Give IM doses of 1 in 1000 adrenaline into the lateral thigh (can repeat after 5 mins if not improving). Avoid subcutaneous administration and do not use IV bolus adrenaline unless cardiac arrest is likely. Nebulized adrenaline can be used as adjunctive therapy (to IM) but not as 1st line.
Dosing can be 0.01ml/kg of 1 in 1000, or if it is easier to remember:
- <6 years old: 150mcg (0.15 mL) IM
- 6-12 years old: 300mcg (0.3 mL) IM
- >12 years old: 500mcg (0.5 mL) IM
- Adult: 500mcg (0.5 mL) IM
Thain S, Rubython J. Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin Hospital, New Zealand. N Z Med J, 2007;120:1252.
Droste J, Narayan N. Hospital doctor’s knowledge of adrenaline (epinephrine) administration in anaphylaxis in adults is deﬁcient. Resuscitation 2010;81:1057–8.