Medication Safety Monday – Part 3

Cite this article as:
Henry Goldstein. Medication Safety Monday – Part 3, Don't Forget the Bubbles, 2014. Available at:

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


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


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.


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.



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 Published 27 Aug 2014. Accessed 28 Oct 2014.


Medication Safety Monday – Part 2

Cite this article as:
Henry Goldstein. Medication Safety Monday – Part 2, Don't Forget the Bubbles, 2014. Available at:

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 second in a series of five brief reviews. 

Since the Kaushal paper, a 2009 New Zealand study by Kunac et al prospectively looked specifically at Adverse Drug Events (ADEs) in paediatric inpatients. ADEs are “actual injuries resulting from medical interventions related to a medicine”. This is a more eloquent patient-oriented outcome – it focuses on those events which have real-world consequences.

More Bottom Lines:

Adverse Drug Events (ADEs) are a patient-oriented outcome.

ADEs occurred about 1 in every 50 prescriptions.

For every hundred admissions, there are about 22 preventable ADEs or potential ADEs.

More than half of the ADEs are preventable.

ADEs are a significant drain on hospital resources.


Kunac DL, Kennedy J, Austin N, Reith D. Incidence, preventability, andimpact of Adverse Drug Events (ADEs) and potential ADEs in hospitalized children in New Zealand: a prospective observational cohort study. PaediatrDrugs. 2009;11(2):153-60. doi: 10.2165/00148581-200911020-00005. PMID19301935 (it’s paywalled, sorry!)


All paediatric & neonatal admissions to a tertiary hospital in Dunedin, NZ in a 12-week period. Patients admitted with overdose were excluded. A total of 520 admissions were analysed (a further ~180 were excluded as length of stay was <24hrs). 


Kunac et al aimed to evaluate the incidence, preventability & seriousness of ADEs (and potential ADEs) in the paediatric inpatient setting in NZ, and their cost implications. 


Information was gathered via chart review, MDT attendances, parent/carer interviews & informal reporting via staff.

What was found?

67 ADEs were identified, at a rate of 2.1 per 100 prescription episodes. Of these, more than half were classified as preventable. An additional 77 potential ADEs were noted.

The numbers have also been analysed on a per admission basis; for every 100 admissions there were ~22 preventable occurrences that were potential or actual ADEs.

Quite correctly, the authors looked at the seriousness of the events. They classified ADEs and Potential ADEs as fatal, persistent disability, life threatening, hospitalisation, intervention to prevent permanent impairment or not serious.

Thankfully, there were no fatal ADEs during the study period, however three events, all in neonates resulted in ‘preventable persistent disability’. Two of the events were related to ‘inadequate management’ of hyponatremia, and a third related to concomitant administration of vancomycin & indomethacin and increasing levels of creatinine.

A further seven further ADEs were life threatening, and seven more as requiring intervention to prevent permanent impairment, all of which were preventable ADEs.

A few specific examples of potential ADEs given include:

  • No maximum dose on a PRN morphine prescription (potentially fatal).
  • Gentamicin dosing & frequency in neonates (persistent disability).
  • A high number of ADE reports centred around opiate medications.

I think it’s good that the authors have been specific about these events; they’re illustrative of how ADEs increase in seriousness quite insidiously, as though sliding through the Swiss Cheese. It’s a nice mix of the data, but with those practical stories that help this kind of research stick.

Finally, there are several paragraphs discussing the costs of ADEs, incorporating causality and costs. They are a quantified as a significant expenditure. I think that as there’s all kinds of volatility in repeating a dollar amount that’s more than a decade old in a small country I’ll refrain from re-posting it. It is worth noting that there’s comprehensive universal healthcare and significant Tort Law reform in New Zealand, so this cost would be about as under inflated as it gets in the developed world.

[Dr Desireé Kunac PharmD. was my supervisor for the aforementioned elective.]

Anaphylaxis and dosing errors

Cite this article as:
Tessa Davis. 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.

Anaphylaxis guidelines, Royal Children’s Hospital, Melbourne.