1.  Plan Ahead – Minimizing the Risk of Pediatric Medication Errors Implications for Disaster Medicine William Fales, MD, FACEP Michigan State University Kalamazoo Center for Medical Studies 5 th District Medical Response Coalition Kalamazoo County Medical Control Authority

2. Acknowledgment Funding for the MI PEEDS Study was provided by the: US Department of Health and Human Services Health Resources and Services Administration Bureau of Maternal and Child Health EMS for Children Program

3. Disclosures Nothing to Disclose

4.  Kids in Disasters

5. Fortunately

6. Also, Fortunately

7. Fundamental Disaster Medicine Concepts  Effective response to an MCI involves application of basic and advanced skills and critical clinical decision making with limited resources.  Being able to respond to day-to-day incidents improves (but does not guarantee) your ability to respond to the “big ones”.  Corollary: If you can’t handle the “little ones” effectively, you sure won’t be able to handle the “big ones”.

8.  Pediatric Medication Errors

9. Medication Challenges in EMS (A Tail of 4 Michigan Studies)  Hoyle Study: EMS Med Dosing Errors in Peds  Lammers Study: Root Cause Analysis of Errors in Simulated Peds Emergency  Michigan EMS Information System Peds Seizure Study  RAMPART Study

10. Med Dosing Errors in Peds Treated by EMS  Prehospital Emergency Care  Hoyle, et al  January/March 2012  Retrospective review of MERMaID Records  Jan 1, 2004 to March 31, 2006  Correct Dose = +/- 20% of protocol dose

12. Weight vs. Age

13. Age Distribution

14. Incorrect Medication Doses, Overdoses and Underdoses

15. Conclusion Medications delivered to children in the prehospital setting by paramedics were frequently administered at doses outside of the proper range when compared with documented patient weights. EMS systems should develop strategies to reduce pediatric medication dosing errors.

16. MI PEEDS Study  MI Pediatric Excellence and Error Detection with Simulation Study  EMS-C Targeted Issues Grant  Academic Emergency Medicine  Lammers, et al  January 2012

17. Participating Agencies

18. Mobile Pediatric Simulation Unit

19. Seizing Infant Benzo Dosing (N=45)

20. Drug Administration

21. Needle end Needle end Plunger direction Diazepam Volume delivered Volume remaining Drug Administration

22. Toddler with Anaphylactic Shock  Epinephrine 1:1000 IM/SQ  Correct dose in 15 of 57 cases (26%)  14 of 57 (25%) gave >10x protocol dose  9 of 57 (16%) gave IV Epi (4 pushing 1:1000)  3 of 5 agencies carried 30 mg multi-dose vials (1:1000)  Diphenhydramine IV/IO/IM  Correct dose in 7 of 54 cases (7%)  Solumedrol IV/IO  Only attempted by 3 of 60 crews (5%)  None with correct dose.

23. MI-EMSIS Peds Seizure Study  Retrospective review of Michigan EMS Information System  2010 Statewide data  944,415 EMS records (all ages)  9,168 Under 2 years old (~1%)  63 received a benzodiazepines (<7%) for seizure

24. Benzo Dosing Midazolam (N=28)  IV/IO  2 of 8 (25%) Correct Dose  IM  3 of 11 (27%) Correct Dose  Rectal  5 (18%) (wrong route)  Active Error Rate=79% Diazepam (N=35)  IV/IO  2 of 6 (33%) Correct Dose  Rectal  5 of 13 (38%) Correct Dose  IM (wrong route)  1 patient  Active Error Rate=65%

25. Summary of Studies  Hoyle Study: 23% to 100% dosing error rate  MI PEEDS Study: 25% to 93% dosing error rate  MI EMSIS Study: 62% to 75% dosing error rate  Studies limited to EMS (high performance EMS)  Do other health professionals do better?

26. Implications in Disaster Medicine  Higher than usual level of emotional stress  Emergency personnel task overloaded  Use of non-emergency personnel for augmentation  e.g., Ortho nurse pulled to ED  Need for highly potent meds with significant risks  Analgesics, sedatives, neuromuscular blockers, ACLS meds  Use of alternative, unfamiliar meds  Unknown pediatric patient weights

27. Plan Ahead – Minimizing Risk of Pediatric Medication Errors  People  Practice and Practices  Protocols  Paraphernalia

28. People  Training and Education  Increased use of existing standardized courses (PALS/PEPP)  Increased emphasis on safe med administration  More frequent, brief continuing education sessions  60 minutes twice a year vs. 4 hours every 2 years  Simulation-based training  High intensity, small group  Does not require high-fidelity simulators

29. Knowledge Assessment Q. “What is the dose of Benadryl for an 8 kg infant who is in anaphylaxis?” A. 1 mg/kg IM or IV

30. Performance-Based Assessment Q. “This simulated infant is in anaphylaxis and has received epinephrine. An IV line is in place. Give another drug. Q. “This simulated infant is in anaphylaxis and has received epinephrine. An IV line is in place. Give another drug.”

31. Performance-Based Assessment Answer: 1. Recall “Benadryl.” 2. Recall or look up the dose: 1 mg/kg IV. 3. Calculate the dose in mgs: 1 mg/kg x 8 kg = 8 mg

32. 4. Find the concentration on the bottle.

33. 5. Convert a weight dose to a volume dose. 8 mg 50 mg/mL = 0.16 mL

34. 6. Draw 0.16 mL out of the vial with a 1 mL syringe.

35. 7. Find the closest port on the IV line. 8. Attach the syringe without contaminating the line. 9. Clamp the line upstream. 10. Deliver the entire volume.

36. Practice and Practices  Practice (Exercising)  Include peds in EMS and hospital exercises  Require simulated med administration  Use wireless ped simulators  Practices  Mandatory buddy-check for all pediatric med administration  Requires culture change  Challenges with single paramedic crews  No fault med error reporting systems  Provide info on near misses/hits >>>> Safety solutions

37. Protocols  Greatly simplify dosing protocols  Avoid non-whole numbers  Broad, simple doses  Epi-Pen vs. Epi-Pen Jr.  Use single doses when appropriate  Glucagon IM for hypoglycemia  Can this be done safely?

38. RAMPART Study  R apid A nticonvulsant M edications P rior to A rrival T rial  New England Journal of Medicine  Silbergliet, et al  Feb 16, 2012  Multi-Center Randomized Trial  Including Detroit EMS  Compare  Midazolam 10 mg IM  (13-40 kg 5 mg IM)  Lorazepam 4 mg IV  (13-40 kg 2 mg IV)

39. RAMPART Findings  Conclusion: For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation.

40. Paraphernalia  Autoinjectors  Limited availability (Epi Pen, AtroPen, Glucagon +/-)  Broselow® Pediatric Emergency Tape  Limitations  Pediatric Dosing Cards  Under development

41. Thematic Qualitative Assessment Wrong end of tape used End of tape not aligned with head Forgot to use Broselow tape WrongWeightWrongWeight Equipment: Use of Broselow tape for weight estimate: Cognitiveerror Procedureerror Procedureerror Used mother’s estimate rather than Broselow tape Cognitiveerror Unfamiliar with Broselow tape Cognitiveerror

42. Thematic Qualitative Assessment Volume measured from wrong end of pre-filled syringe Mg to mL conversion error DrugDoseErrorDrugDoseError Wrong weight Mg/kg to mg calculation error calculation error Unaided calculations Failure to cross-check calculations Impaired calculation ability under stress ability under stress Affectiveerror Teamworkerror Cognitiveerror Procedureerror Cognitiveerror Cognitiveerror Cognitiveand/orprocedureerror Drug Delivery: Wrong mg/kg dose for route for route Cognitiveerror DrugDosingCards?DrugDosingCards?

43. LA County Peds Cards

44. 6-7 Kg6-7 (13-15 Lbs)/ 3-6 Months (Pink) Resuscitation MedicationDoseVolume EPINEPHRINE 1:10,000 (1mg/10mL prefill).07 mg 0.7 ml AMIODARONE (150mg/3mL) 25 mg 0.5 ml LIDOCAINE (100mg/5mL) 5 mg 0.25 ml MAGNESIUM SULFATE (1gm/2mL) 250 mg 0.5 ml CALCIUM CHLORIDE (1gm/10mL) 100 mg 1 ml ADENOSINE (6mg/2mL) – 1 st Dose.65 mg 0.2 ml ADENOSINE (6mg/2mL) – 2 nd Dose 1.3 mg 0.4 ml Electrical TherapyInitialRepeat Defibrillation 15 J25 J Cardioversion (synchronized) 10 J15 J MI Peds Card (Prototype)

45. 6-7 Kg (13-15 Lbs)/ 3-6 Months (Pink) Assessment Normal Vitals: HR: 100-160, RR: 30-60, SBP: >70, Development: Rolls from front to back, back to side. Carries object to mouth DrugDoseVolumeDrugDoseVolume Asthma Anaphylaxis Albuterol (2.5 mg/3 ml) 2.5 mg 3 ml Epinephrine (1 mg/ml) IM 0.1 mg 0.1 ml Diphenhydramine (50 mg/ml) 10 mg 0.2 ml Solumedrol (125 mg/2 ml) 19 mg 0.3 ml Seizure Midazolam IM (5 mg/1 ml) 1 mg 0.2 ml Diazepam PR (10 mg/2 ml) 3 mg 0.6 ml Midazolam IV slow (5 mg/1 ml+4 ml NSS=1 mg/ml)).5 mg 1 ml (diluted) Diazepam IV slow (10 mg/2 ml + 8 ml NSS=1 mg/ml) 1 mg 1 ml (diluted) Hypoglycemia Dextrose 25% Slow IV 15 ml Glucagon IM (1 mg/ml) 1 mg 1 ml Pain Control Fentanyl IV (100 mcg/2 ml) 5 mcg 0.1 ml Morphine IV (10 mg/ml + 9 ml NSS=10mg/10 ml) 0.5 mg.5 ml (diluted) Fentanyl IN (100 mcg/ml) 10 mcg.2 ml Morphine IM (10 mg/ml) 1 mg 0.1 ml Narcotic OD Naloxone IV/IM (2 mg/2 ml) 1 mg 1 ml Naloxone IN (2 mg/2 ml) 1 mg 1 ml Fluid Bolus Normal Saline IV/IO 130 ml May repeat NSS x2 PRN 130 ml Equipment OPA: 50mm, NPA: 14F, BVM: Infant, Laryngoscope: 1 (straight), ET Tube: 3.5, ET Depth: 11 cm

46. Summary  Caring for critically ill and injured kids is extremely stressful  Disasters greatly increase stress  Pediatric medication errors are common  During a disaster med errors could significantly increase  There are many ways to potentially reduce ped med errors  By reducing pediatric medication errors on a “routine” basis, we will provide safer, more effective care in a disaster Thanks! Fales@kcms.msu.eduFales@kcms.msu.edu