title: Medication errors in prehospital management of simulated pediatric anaphylaxis.
abstract: BACKGROUND
  Systematic evaluation of the performances of prehospital providers during actual pediatric anaphylaxis cases has never been reported. Epinephrine medication errors in pediatric resuscitation are common, but the root causes of these errors are not fully understood.
  
  
  OBJECTIVE
  The primary objective of this study was to identify underlying causes of prehospital medication errors that were observed during a simulated pediatric anaphylaxis reaction.
  
  
  METHODS
  Two- and 4-person emergency medical services crews from eight geographically diverse agencies participated in a 20-minute simulation of a 5-year old child with progressive respiratory distress and hypotension from an anaphylactic reaction. Crews used their own equipment and drugs. A checklist-based scoring protocol was developed to help identify errors. A trained facilitator conducted a structured debriefing, supplemented by playback of video recordings, immediately after the simulated event to elicit underlying causes of errors. Errors were analyzed with mixed quantitative and qualitative methods.
  
  
  RESULTS
  One hundred forty-two subjects participated in 62 simulation sessions. Ninety-five percent of crews (59/62) gave epinephrine, but 27 of those crews (46%) delivered the correct dose of epinephrine in an appropriate concentration and route. Twelve crews (20%) gave a dose that was ≥5 times the correct dose; 8 crews (14%) bolused epinephrine intravenously. Among the 55 crews who gave diphenhydramine, 4 delivered the protocol-based dose. Three crews provided an intravenous steroid, and 1 used the protocol-based dose. Underlying causes of errors were categorized into eight themes: faulty reasoning, weight estimation errors, faulty recall of medication dosages, problematic references, calculation errors, dose estimation, communication errors, and medication delivery errors.
  
  
  CONCLUSIONS
  Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions. Sequential and synergistic errors were observed with epinephrine delivery.
authors.forename: Richard
authors.initials: R
authors.lastname: Lammers
authors.forename: Maria
authors.initials: M
authors.lastname: Willoughby-Byrwa
authors.forename: William
authors.initials: W
authors.lastname: Fales
mesh_terms: D000488:Allied Health Personnel / Q000592:standards / Q000706:statistics & numerical data; D000707:Anaphylaxis / Q000188:drug therapy*; D002675:Child, Preschool; D002983:Clinical Competence; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data*; D004634:Emergency Medical Technicians / Q000592:standards / Q000706:statistics & numerical data*; D004837:Epinephrine / Q000008:administration & dosage* / Q000592:standards / Q000627:therapeutic use; D005069:Evaluation Studies as Topic; D005260:Female; D006801:Humans; D008297:Male; D008348:Manikins; D008508:Medication Errors / Q000706:statistics & numerical data*; D008824:Michigan; D016544:Patient Simulation; D010372:Pediatrics / Q000379:methods / Q000592:standards; D036301:Qualitative Research; D014662:Vasoconstrictor Agents / Q000008:administration & dosage / Q000627:therapeutic use; D000078329:Workforce
chemical_list: D014662:Vasoconstrictor Agents; D004837:Epinephrine