Enhancing Pediatric Patient Safety Karen Frush MD, FAAP Susan Hohenhaus MA, RN, FAEN A Report to the A Report to the 2006 EMSC Grantee Meeting

Leape L: Error in Medicine. JAMA; 1994:272(23); “Epidemic of errors in healthcare” “Most errors are made by good but fallible people, working in a challenged and imperfect system.”

Challenges in Pediatric Emergency Care ED is high risk, highly complex environment ED is high risk, highly complex environment Lack of standardized dosing or equipment sizing Lack of standardized dosing or equipment sizing Limited opportunity for prescription monitoring Limited opportunity for prescription monitoring Lack of pediatric trained emergency providers Lack of pediatric trained emergency providers Emotional stress of pediatric care Emotional stress of pediatric care Hectic, chaotic, interruptions and time limitations Hectic, chaotic, interruptions and time limitations … challenged and imperfect system in pediatric emergency care

Patterns of Error and System Improvement “Systems failure” as a common cause of error “Systems failure” as a common cause of error Lack of standardization leads to many errors in pediatric emergency care Lack of standardization leads to many errors in pediatric emergency care Simplification and redundancy can improve system and minimize cognitive load of human providers Simplification and redundancy can improve system and minimize cognitive load of human providers

The Use of Resuscitative Aids in Pediatric Emergency Care Pre-calculated dosing charts have been used extensively to reduce error Pre-calculated dosing charts have been used extensively to reduce error Requires known weight Requires known weight Broselow Resuscitation Tape ™ is the only method currently combining the two Broselow Resuscitation Tape ™ is the only method currently combining the two Available for 15 years Available for 15 years Available in EDs, offices and ALS vehicles across U.S. Available in EDs, offices and ALS vehicles across U.S.

Use of the Broselow Resuscitation Tape ™: Pro vs Con When properly implemented, the Tape incorporates many facets of sound systems. When properly implemented, the Tape incorporates many facets of sound systems. Weight estimation and manual dose calculation bypassed: pre- calculated dose, pre-determined equipment size Weight estimation and manual dose calculation bypassed: pre- calculated dose, pre-determined equipment size Allows for ‘double-checking’ (lb/kg) Allows for ‘double-checking’ (lb/kg) Used beyond the ED: reduced radiation dose of CT scans Used beyond the ED: reduced radiation dose of CT scans Allows the clinicians to focus on assessment, prioritization, intervention and communication Allows the clinicians to focus on assessment, prioritization, intervention and communication Shown to reduce deviation from recommended dose range Shown to reduce deviation from recommended dose range Shah N, Frush K, Luo X, Wears R: Impact of an intervention standardization system on pediatric dosing and equipment sizing. Arch of Pediatr Adolesc Med. 2003;157:

Use of the Broselow Resuscitation Tape ™: Pro vs Con Problems with tape itself Problems with tape itself Hohenhaus SM, Frush KS. Pediatric patient safety: common problems in the use of resuscitative aids for simplifying pediatric emergency care. J Emerg Nurs 2004.Feb;30(1):49-51 Morgan N, Fortner C, Luo X, Frush KS. Opportunities for improvement in medication administration during a simulated pediatric emergency event. Qual and Safety in Healthcare (3) Problems in use of tape Problems in use of tape Not used often; difficult to locate; “intuitive” yet rarely used correctly Not used often; difficult to locate; “intuitive” yet rarely used correctly Recurrent patterns of incorrect use Recurrent patterns of incorrect use Incorrect measurement, measure from wrong end Incorrect measurement, measure from wrong end Tape used to get weight, then doses calculated Tape used to get weight, then doses calculated

Main Objective of the Duke EPPS EMSC Project To develop and evaluate a web-based educational course and training program to increase the appropriate use of the Broselow Resuscitation Tape ™ in order to decrease error in pediatric emergency stabilization events. To develop and evaluate a web-based educational course and training program to increase the appropriate use of the Broselow Resuscitation Tape ™ in order to decrease error in pediatric emergency stabilization events. Frush K. Hohenhaus S. Luo X, Gerardi M, Weibe RA. Evaluation of a Web-based education program on reducing medication dosing error: a multi-center, randomized controlled trial. Pediatr Emerg Care Jan;22(1):62-70 Frush K. Hohenhaus S. Luo X, Gerardi M, Weibe RA. Evaluation of a Web-based education program on reducing medication dosing error: a multi-center, randomized controlled trial. Pediatr Emerg Care Jan;22(1):62-70

EPPS: Methods and Evaluation Multi-center randomized controlled trial Multi-center randomized controlled trial Observational study, comparing medication dosing error pre and post-intervention (web-based module) Observational study, comparing medication dosing error pre and post-intervention (web-based module) Conducted on-site, low-fidelity simulated pediatric stabilization scenario pre and post; all videotaped Conducted on-site, low-fidelity simulated pediatric stabilization scenario pre and post; all videotaped Emphasis on decision-making, not skills Emphasis on decision-making, not skills 88 participants pre-intervention; 86 post- intervention at 3 sites: Attending MD, Fellows, Residents, RNs, EMT-Ps 88 participants pre-intervention; 86 post- intervention at 3 sites: Attending MD, Fellows, Residents, RNs, EMT-Ps

EPPS: Results No significant difference observed in demographic characteristics of the 2 groups. No significant difference observed in demographic characteristics of the 2 groups. After the educational intervention, average (12.6% vs. 24.9%) and median (7.1% vs. 20.1%) dosing deviation summary were significantly lower in education group than in control group (P = ). After the educational intervention, average (12.6% vs. 24.9%) and median (7.1% vs. 20.1%) dosing deviation summary were significantly lower in education group than in control group (P = ). Education group demonstrated a lower average (16 vs. 20 seconds) and lower median (15 vs. 18 seconds) dosing time summary than control group. (P = 0.02). Education group demonstrated a lower average (16 vs. 20 seconds) and lower median (15 vs. 18 seconds) dosing time summary than control group. (P = 0.02). Analysis of each medication prescribed indicated that decrease in dosing deviation and dosing time in education group was most obvious for several specific medications: dopamine, dextrose, vecuronium Analysis of each medication prescribed indicated that decrease in dosing deviation and dosing time in education group was most obvious for several specific medications: dopamine, dextrose, vecuronium

EPPS: CONCLUSIONS The Web-based education program on the proper use of the Broselow Pediatric Resuscitation Tape can improve dosing accuracy and reduce dosing time. The Web-based education program on the proper use of the Broselow Pediatric Resuscitation Tape can improve dosing accuracy and reduce dosing time. Barriers to use Barriers to use Proprietary product: defects can’t be easily corrected Proprietary product: defects can’t be easily corrected Clinicians’ resistance to standardization Clinicians’ resistance to standardization JCAHO mandate on standard infusions JCAHO mandate on standard infusions

Products Supported by Grant Funding Website: Website: Study Packet for the use of the Broselow Tape (new addendums in 2006 for new Tape and other CCK resuscitation guidelines) Study Packet for the use of the Broselow Tape (new addendums in 2006 for new Tape and other CCK resuscitation guidelines) Practical Guide to Pediatric Emergency Readiness: Conducting Simulations in the Clinical Setting Practical Guide to Pediatric Emergency Readiness: Conducting Simulations in the Clinical Setting Pediatric Mass Casualty Guidelines: PAT, JUMPSTART, color-coded antidotes Pediatric Mass Casualty Guidelines: PAT, JUMPSTART, color-coded antidotes Much more work to do… Much more work to do…

Improving Patient Safety in Pediatric Emergency Care: Consensus Meeting of PEM Experts Two multidisciplinary meetings (2004 and 2005) Two multidisciplinary meetings (2004 and 2005) Met to discuss pediatric patient safety issues such as lack of standardized approach to medication administration; pediatric specific quality indicators, team training (CRM), culture of safety Met to discuss pediatric patient safety issues such as lack of standardized approach to medication administration; pediatric specific quality indicators, team training (CRM), culture of safety Recommendations for partnerships; need for conference calls and additional meetings; need for further development of guidelines and studies specific to pediatric patient safety in emergency care across the continuum Recommendations for partnerships; need for conference calls and additional meetings; need for further development of guidelines and studies specific to pediatric patient safety in emergency care across the continuum

Ongoing efforts to improve Patient Safety COPEM and ACEP statements COPEM and ACEP statements ENA ENA PECARN PECARN AHRQ grants: M Patterson AHRQ grants: M Patterson AAP Safer Healthcare for Kids AAP Safer Healthcare for Kids Individual institutions: Individual institutions: Walk rounds: CHOP Walk rounds: CHOP Team training: DUHS Team training: DUHS

Summary Pediatric emergency care continues to be very challenging Pediatric emergency care continues to be very challenging Evidence suggests that standardization and the use of tools and techniques to support consistent use could enhance pediatric patient safety Evidence suggests that standardization and the use of tools and techniques to support consistent use could enhance pediatric patient safety Tools exist but there is still reluctance to fully utilize them or educate consistently Tools exist but there is still reluctance to fully utilize them or educate consistently Need further development, revision and validation of tools and educational programs that support their use Need further development, revision and validation of tools and educational programs that support their use

Many Thanks… EMSC EMSC Bob Weibe, MD Bob Weibe, MD Mike Gerardi, MD Mike Gerardi, MD Xuemei Luo, PhD Xuemei Luo, PhD Our partnership groups (AAP, COPEM, ACEP, ENA, ISMP and others) Our partnership groups (AAP, COPEM, ACEP, ENA, ISMP and others)