Empirical Investigations
Errors and Error-Producing Conditions During a Simulated, Prehospital, Pediatric Cardiopulmonary Arrest Richard L. Lammers, MD; Maria Willoughby-Byrwa, BS, EMT-P, I/C; William D. Fales, MD
Introduction: Management of pediatric cardiac arrest challenges the skills of prehospital care providers. Errors and error-producing conditions are difficult to identify from retrospective records. The objective of this study was to identify errors committed by prehospital care providers and the underlying causes of those errors during a simulated pediatric cardiopulmonary arrest followed by a structured debriefing. Methods: Performance criteria were defined prospectively by an advisory panel. Prehospital care providers from 6 emergency medical service agencies in Michigan participated in a simulation of an infant cardiopulmonary arrest using their own drugs, equipment, and protocols in a mobile trailer. Simulations were video recorded and played back during debriefings that were conducted immediately after the event to facilitate error analysis. Observed errors and subjects’ explanations were analyzed by thematic qualitative assessment methods and descriptive statistics. Results: One hundred ninety-four subjects, including paramedics, emergency medical technicians, and emergency medical responders in various crew configurations, participated in 60 simulation sessions during a 5-month period (April to August of 2010). Error types were classified into 4 clinically important themes as follows: failure to provide adequate ventilation, failure to provide effective circulation, failure to achieve vascular access rapidly, and medication errors. Multiple underlying causes of medication dosing and other errors were identified, including cognitive, procedural, communication, teamwork, and systems factors. Conclusions: We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors. (Sim Healthcare 9:174Y183, 2014)
Key Words: Emergency medical services, Simulation, Pediatric emergencies, Medical errors
T
he frequency and types of errors in the prehospital management of pediatric patients are not fully known and are likely to be underreported.1,2 Superficial analysis of errors may overlook a chain of preceding events or contributory factors that precipitated the failure.3 Emergency medical service (EMS) providers have reported that common reasons for errors include deviation from protocols, confusing or nonstandard protocols, equipment incompatibilities, difficult field conditions, problems with procedural skill performance, medication dose calculations, and improper equipment sizes.
From the Department of Emergency Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan. Reprints: Richard Lammers, MD, Western Michigan University School of Medicine, Research Director, Department of Emergency Medicine, 1000 Oakland Dr, Kalamazoo, MI 49008-1284 (e45 s during intubation; otherwise >15 s). Intubation: g Attempt intubation before BVM ventilations. g Fail to recognize an esophageal intubation within 60 s. Attempt prolonged intubation for >1.5 min (without preoxygenation) or >2.5 min (with preoxygenation). Medications: g Give epinephrine 1:1000 concentration 0.6Y0.9 mL ET (10x IO dose) (concentration, 1.0 mg/mL; dose, 0.1 mg/kg, or 0.1 mL/kg) g Give atropine Second round of medications: g Give epinephrine 1:1000 concentration 0.4Y0.5 mL ET. g Give atropine
Adequate
Optimal
Circulation: g Check pulse. g Begin chest compressions. g Attach cardiac monitor electrodes to chest. g Perform compressions at a rate of 100/min. History: g Obtain a history. IV/IO access: g Attempt an IV (fails). g Abandon attempt at IV line within 90 s. g Insert IO line in the correct location (anywhere in proximal half of tibia.) and attach tubing. Medications: g Use Broselow tape to obtain weight. Color:_____ g Obtain correct weight from tape (6Y8 kg). g Use Broselow tape to obtain drug doses. g Give epinephrine 1:10,000 concentration, 0.6Y0.9 mL IO (concentration, 0.1 mg/mL; dose, 0.01 mg/kg, or 0.1 mL/kg) or, g Check cardiac rhythm on monitor after 2 min. g Check cardiac rhythm on monitor after 2 min. g Check pulse after 2 min (absent). Intubation (optional procedure): g Select correct size laryngoscope blade (1.0 straight). Actual size:_____ g Select correct ET tube size (3.5Y4.0). Actual size:_____ g Confirm placement. g Secure ET tube (tape or pediatric tube holder). g Insert/secure ET tube to proper depth (3x tube size þ/j 1 cm, or 10Y13cm) actual depth:_____ g Perform successful intubation g No. attempts:_____ Second round of medications: g Repeat initial dose of epinephrine within 3Y5 min of first dose: g Give epinephrine 1:10,000 concentration. g 0.6Y0.9 mL IO, or g Check cardiac rhythm on monitor after 2 min. g Check pulse after 2 min.
g Put on face and eye protection before IV/IO. g Set up and turn on suction. g Reassure mother. g Confirm measured weight from Broselow tape with mother’s history. g Cross-check drug calculations and volume of drug (partner or reference) before delivery. g Auscultate gastric area before lungs after intubation. Medication delivery process:
No. attempts:
Phase 3: Recovery Outcome: Identify change in rhythm and provide a fluid bolus. Unacceptable
Adequate g Deliver a fluid bolus of 100þ/j20 mL (20 mL/kg) of normal saline solution at any point after PEA develops.
Vol. 9, Number 3, June 2014
Optimal g Recheck capillary refill, skin temp, or tone after recovery of pulse.
* 2014 Society for Simulation in Healthcare
Copyright © 2014 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
183
Errors and Error-Producing Conditions During a Simulated, Prehospital, Pediatric Cardiopulmonary Arrest Richard L. Lammers, MD; Maria Willoughby-Byrwa, BS, EMT-P, I/C; William D. Fales, MD
Introduction: Management of pediatric cardiac arrest challenges the skills of prehospital care providers. Errors and error-producing conditions are difficult to identify from retrospective records. The objective of this study was to identify errors committed by prehospital care providers and the underlying causes of those errors during a simulated pediatric cardiopulmonary arrest followed by a structured debriefing. Methods: Performance criteria were defined prospectively by an advisory panel. Prehospital care providers from 6 emergency medical service agencies in Michigan participated in a simulation of an infant cardiopulmonary arrest using their own drugs, equipment, and protocols in a mobile trailer. Simulations were video recorded and played back during debriefings that were conducted immediately after the event to facilitate error analysis. Observed errors and subjects’ explanations were analyzed by thematic qualitative assessment methods and descriptive statistics. Results: One hundred ninety-four subjects, including paramedics, emergency medical technicians, and emergency medical responders in various crew configurations, participated in 60 simulation sessions during a 5-month period (April to August of 2010). Error types were classified into 4 clinically important themes as follows: failure to provide adequate ventilation, failure to provide effective circulation, failure to achieve vascular access rapidly, and medication errors. Multiple underlying causes of medication dosing and other errors were identified, including cognitive, procedural, communication, teamwork, and systems factors. Conclusions: We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors. (Sim Healthcare 9:174Y183, 2014)
Key Words: Emergency medical services, Simulation, Pediatric emergencies, Medical errors
T
he frequency and types of errors in the prehospital management of pediatric patients are not fully known and are likely to be underreported.1,2 Superficial analysis of errors may overlook a chain of preceding events or contributory factors that precipitated the failure.3 Emergency medical service (EMS) providers have reported that common reasons for errors include deviation from protocols, confusing or nonstandard protocols, equipment incompatibilities, difficult field conditions, problems with procedural skill performance, medication dose calculations, and improper equipment sizes.
From the Department of Emergency Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan. Reprints: Richard Lammers, MD, Western Michigan University School of Medicine, Research Director, Department of Emergency Medicine, 1000 Oakland Dr, Kalamazoo, MI 49008-1284 (e45 s during intubation; otherwise >15 s). Intubation: g Attempt intubation before BVM ventilations. g Fail to recognize an esophageal intubation within 60 s. Attempt prolonged intubation for >1.5 min (without preoxygenation) or >2.5 min (with preoxygenation). Medications: g Give epinephrine 1:1000 concentration 0.6Y0.9 mL ET (10x IO dose) (concentration, 1.0 mg/mL; dose, 0.1 mg/kg, or 0.1 mL/kg) g Give atropine Second round of medications: g Give epinephrine 1:1000 concentration 0.4Y0.5 mL ET. g Give atropine
Adequate
Optimal
Circulation: g Check pulse. g Begin chest compressions. g Attach cardiac monitor electrodes to chest. g Perform compressions at a rate of 100/min. History: g Obtain a history. IV/IO access: g Attempt an IV (fails). g Abandon attempt at IV line within 90 s. g Insert IO line in the correct location (anywhere in proximal half of tibia.) and attach tubing. Medications: g Use Broselow tape to obtain weight. Color:_____ g Obtain correct weight from tape (6Y8 kg). g Use Broselow tape to obtain drug doses. g Give epinephrine 1:10,000 concentration, 0.6Y0.9 mL IO (concentration, 0.1 mg/mL; dose, 0.01 mg/kg, or 0.1 mL/kg) or, g Check cardiac rhythm on monitor after 2 min. g Check cardiac rhythm on monitor after 2 min. g Check pulse after 2 min (absent). Intubation (optional procedure): g Select correct size laryngoscope blade (1.0 straight). Actual size:_____ g Select correct ET tube size (3.5Y4.0). Actual size:_____ g Confirm placement. g Secure ET tube (tape or pediatric tube holder). g Insert/secure ET tube to proper depth (3x tube size þ/j 1 cm, or 10Y13cm) actual depth:_____ g Perform successful intubation g No. attempts:_____ Second round of medications: g Repeat initial dose of epinephrine within 3Y5 min of first dose: g Give epinephrine 1:10,000 concentration. g 0.6Y0.9 mL IO, or g Check cardiac rhythm on monitor after 2 min. g Check pulse after 2 min.
g Put on face and eye protection before IV/IO. g Set up and turn on suction. g Reassure mother. g Confirm measured weight from Broselow tape with mother’s history. g Cross-check drug calculations and volume of drug (partner or reference) before delivery. g Auscultate gastric area before lungs after intubation. Medication delivery process:
No. attempts:
Phase 3: Recovery Outcome: Identify change in rhythm and provide a fluid bolus. Unacceptable
Adequate g Deliver a fluid bolus of 100þ/j20 mL (20 mL/kg) of normal saline solution at any point after PEA develops.
Vol. 9, Number 3, June 2014
Optimal g Recheck capillary refill, skin temp, or tone after recovery of pulse.
* 2014 Society for Simulation in Healthcare
Copyright © 2014 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
183
