As a high school student, I was up at the board in front of everyone, staring at a math problem I struggled to solve. After a late-night of video games and entirely too much caffeine to try to compensate for my lack of sleep, I stood up there, all eyes on me, trying to navigate my grogginess and remember basic division. The pressure was on, and my mind was blank. My teacher finally came to my rescue and allowed me to use a calculator and said something I’ll always remember - “Do your best to never perform mental math in public”. It was good advice, but the consequence of adolescent embarrassment is nothing compared to the tragic consequence of making a math error on a pediatric patient. In this week’s update, we will review our tools to help take the math out of pediatric dosing.  

Certa Dose

New for 2021, Certa Dose is a product we’re rolling out to help take the calculations out of some of our PALS medications including epinephrine, atropine, and lidocaine. These are essentially plastic sleeves slid onto the corresponding syringe providing a visual landmark to ensure we are administering the correct dose. It utilizes the Broslow color-coding system, and even comes with a pediatric tape measure to help us determine which Broslow color the patient falls into. This tape is designed to avoid the errors associated with measuring from the wrong side when using the traditional Broslow tape.

Broslow Tape



The traditional fold-up Broslow tape is a great tool to help us determine the correct sizes and doses for the treatments needed to care for our pediatric patients. Many of the medications required to care for pediatric emergencies are listed with the appropriate doses in each color section, helping us take the calculations off of our shoulders. The Broslow tape does have a couple of limitations. We must measure from the correct side of the tape. If we measure from the wrong side, we may vastly under- or overestimate the patient’s weight and therefore under- or overestimate the size of the airway or medication dose required. Always make sure you align the tape properly with the red arrow at the head of the patient. Additionally, to provide as much information as possible, the writing on the tape is very small. For those whose eyesight isn’t quite what it used to be, or in areas with difficult lighting, this small font can be a frustrating challenge.

Pediatric Dosing Charts located within the UH EMS Protocol

Finally, we have pulled all of our information together to provide Pediatric Weight-Based Dosing Charts beginning on page 56|13 of the 2021 R2 UH EMS Protocol. These charts are color-coded based on the Broslow system. It provides the appropriate doses in mg, grams, and mEqs, as well as listing the doses in mLs, so you know exactly how much to draw up and/or administer to your pediatric patient. These charts are not just about medications, they also provide guidance for ET tube size and depth, defibrillation energy, IV catheter size, King Airway information, and other useful pieces of information to help take some of the burdens off the calculations.

Derek Frost, PharmD, MBA, BCPS

Medication Safety - April 12, 2021

Look-alike/Sound-alike Drugs

The human brain can do extraordinary things! Its ability to perform multiple tasks on the conscious and subconscious level is remarkable. For instance, when you brush your teeth or make your morning coffee you aren’t thinking through each step.  You may be thinking about your day ahead, reflecting on the previous day, or maybe taking a stab at solving the world’s problems. Not to mention you don’t have to think about all of the body’s functions at that moment from breathing, beating your heart, digesting last night’s dinner, blinking, or maintaining a proper internal temperature. The short paragraph below is one of those examples of the brain doing something extraordinary. 

"It deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe."

For many of us, the statement above can be read with minimal difficulty, even though the majority of the words are spelled incorrectly. Our brains can use context clues, past experiences, and a little trickery to allow us to read what should be a jumbled mess. This is great for the vast majority of life’s experiences, however, in the great and complicated world of drug names, it can prove quite the challenge. With many similarities in drug names, and packaging (colors, font, label design, shape, etc.), we often mistake one drug for another. At quick glance, our brain tells us that what we just saw is what we were looking for, even though it may not be the correct medication.

The pre-hospital setting is a metaphorical hotbed for potential look-alike/sound-alike errors due to various factors. Those factors include the critical nature of the situation, variable lighting, lack of medication safety technology such as barcode scanning, and  all of the above factors. Sometimes these factors are combined with the fact that it’s 3 a.m. and 5 minutes ago you were sound asleep. For this week’s update, we want to highlight some of the medications within the protocol that are at a relatively higher risk of look-alike/sound-alike errors. The goal is that we identify these higher-risk medications to raise a “red flag” anytime you are reaching for one of these to make sure to give it a second look.

Adenosine/Atropine

If I had a look-alike/sound-alike hall of fame, these are perfect examples since both start with ‘a’, end in ‘ine’, and both are indicated in cardiac arrhythmias. To complicate matters, adenosine has had rolling shortages resulting in vials at times and pre-filled syringes at other times. My trick here is taking advantage of the color standardization with Atropine in the purple box – purple pine.

Labetalol/Lopressor (metoprolol)

This one is a problem with both the brand (Lopressor) and generic names (metoprolol). We have ‘L’ beginning for Lopressor and the same beta-blocker ending of –lol in both generic names. The uses are slightly different with labetalol being both a beta and alpha blocker, with alpha blocking being the major mechanism to cause a sharp lowering of the blood pressure and metoprolol acting as a cardio-selective beta-blocker to lower the heart rate. Ray Pace taught me to think “labor” with labetalol as we will mostly use this for BP lowering in pregnant patients.  

Zyprexa/Zofran – olanzapine/ondansetron

I fell into this look-alike/sound-alike trap early in my career which resulted in my first known medication error (fortunately, the nurse caught it, and it never got to the patient). Both the brand and the generic names sound similar, and additionally, the oral versions of these medications look similar. After a few near-miss situations, I learned to triple and quadruple check any longer drug name starting with an ‘o’ before sending to the patient. I don’t have a good trick for this one, I just get paranoid about it and read it forwards and backwards until I’m 100% sure it’s right….then check it again.

Overall, look-alike/sound-alike errors are a tricky aspect to working with medications. In next week’s update, we will highlight some of the ways we are working to minimize the potential for errors in the field with Tall Man lettering, strategic placement of medications in the boxes, and trying to make them stand out from each other. Improving medication safety is a never-ending journey and it takes all of us! Humans make mistakes, and our amazing brains do fail us occasionally. With careful attention, visual cues, technology, and improving our internal double-checking processes, we help prevent these possible errors from reaching our patients.  

Derek Frost, PharmD, MBA, BCPS

Medicaions - April 19, 2021

Medication Safety Features 

Earlier this year, I had the honor of teaching two lectures on Medication Safety to students in their second year of pharmacy school. To keep a large number of students engaged in what can be a dense, dry, and occasionally confusing topic, I used many stories from news articles, video clips, and my own experience to illustrate how errors occur in the “real world”. After each scenario, I prompted the students with the question of “who is to blame?” My goal over the seven hours of lecture was to shift their mindset from immediately blaming an individual (almost always assumed to be lazy and careless) to identifying process improvement opportunities to promote safety in the medication use system. Although it wasn’t completely successful, at least one student in every scenario said the blame should fall squarely on the individual, rather than the process/medication use system.  We did eventually get to a place of identifying multiple areas of process improvement with each case. Using this mentality of creating a safer medication use system, we are utilizing multiple processes to prevent medication errors for those providing pre-hospital care throughout our communities. After all, we are all human, we all make mistakes, even when we are careful.

Tall Man Lettering

Tall Man Lettering is an FDA and Institute of Safe Medication Practices (ISMP) recommendation aimed to combat some of the look-alike errors associated with drug names. Tall Man Lettering capitalizes the part of the drug name. The capital letters are designed to grab your attention, capitalizing the letters of the drug name that sets it apart from a similar drug name. Some examples of Tall Man Lettering used in the EMS protocol include EPINEPHrine, fentaNYL, OLANZapine, ZyPREXA, methylPREDNISolone, and many others. Tall Man Lettering appears in the protocol each time a recommended drug is mentioned. Note both LORazepam and fentaNYL in this screenshot of the rapid sequence intubation for an adult algorithm.

Kit Check

One of the newer tools in our proverbial tool belt is the product Kit Check. Kit Check uses radio-frequency identification tags to detect the presence of a drug as well as the expiration date and manufacturer lot number. This technology allows the pharmacy to quickly identify where drug boxes are located, which drugs are in the boxes, as well as expiration dates. This information is valuable in many ways. The most immediate benefit is the quick identification of which drugs were removed from the box to be given to a patient and needs to be refilled to go out to the next squad. Additionally, in the event of drug recalls, we can search a manufacturer lot number and determine which boxes contain the drug and begin to make arrangements to swap it out with an unaffected box.  

Unfortunately, the RFID tag cannot tell us if the vial or dose package was used, or if the tagged item is still in the box, so it is vitally important that you do NOT put an empty or partially used vial/dose package back into the box. Kit Check will recognize the tag and make it look like the medication is there and ready to use. Never put a used medication back in the drug box!  

Zyprexa

As mentioned last week, olanzapine (Zyprexa) and ondansetron (Zofran) have been a look-alike/sound-alike concern in my personal practice, and I know I’m not the only one. Although for Zofran, neither the generic name (ondansetron) nor the brand name (Zofran) appears in the FDA or ISMP lists of commonly confused drugs.   In addition to strategically separating the physical location of these medications within the drug box, we are rolling out a process to place the olanzapine (Zyprexa) in a plastic bag with a neon label stating “Zyprexa”. This will hopefully make the less commonly used drug Zyprexa from being used when Zofran is intended.

Our journey as a healthcare team toward zero medication errors is ongoing. As I mentioned last week, careful attention, visual cues, technology, and improving our internal double-check processes can help prevent medication errors from reaching our patients. Medication safety takes all of us, and we are constantly striving to improve our process and provide you all with as many tools as possible to help you care for your patients in a safe and effective manner. 

Derek Frost, PharmD, MBA, BCPS

Medications - April 26, 2021

Drug Shortages

I was born and raised in Northeast Ohio, hurricanes are not something that directly affect my day-to-day life. Every year we watch as hurricanes rip through the Caribbean, Gulf of Mexico, and the Southeastern United States leaving a path of destruction, but for many of us there is minimal impact on our daily life. A few hurricanes are notable for their devastation, Hurricane Katrina, Hurricane Andrew, Hurricane Sandy, and the one I’ll never forget – Hurricane Maria. Hurricane Maria hit Puerto Rico in September of 2017, it was notable for being particularly devastating as a category 5 hurricane, the death toll was remarkable and it destroyed much of Puerto Rico’s power grid. All of this was very sad, but, as with most other hurricanes I watched from a distance and thought “this is why I live in Ohio where the winter air hurts my face, but I don’t have to deal with hurricanes,” Little did I know, this hurricane would soon change everything about our medication use system. What many of us didn’t know at the time was that Baxter, the largest manufacturer of IV fluids in the U.S., had the majority of its operations in Puerto Rico. The following months became a major challenge as the other IV fluid companies tried to keep up with the sharp increase in demand.  The shortage officially ended in June of 2019, nearly two years after the hurricane hit.  

Causes of Drug Shortages

Drug shortages are caused by many different situations – quality issues at manufacturing sites, sharp increases in demand, supply chain complications, companies deciding to no longer make a particular drug or the rare disaster at the manufacturing site. As you can imagine, there are often multiple issues at play – one company stops making a drug, or due to quality issues, has to stop production. This leads to an increased demand for the product from the other companies still making the product, the other companies can’t keep up and we have a shortage. Often, companies are able to recover quickly, or we have options of drugs, and we can pivot to another drug or route of administration.  There are currently 199 drug shortages being tracked and updated by the University of Utah Drug Information Services – the nation’s expert in drug shortages. Some of these shortages are not affecting the amount of drugs we can bring in, and some we have had to switch to different products or routes of administration to still meet our treatment goals for patients. At the local UH level, we are constantly working to keep an inventory of the affected drugs and maintain as much of a supply coming in as possible to meet the demand for our patients in the pre-hospital, inpatient, and outpatient settings.

Preparing for Drug Shortages

Some drugs are more prone to drug shortage than others for various reasons, but most often because there are limited suppliers and problems at manufacturing sites, and more often a combination of the two. Some drugs are particularly concerning when they go on shortage due to a lack of alternatives – epinephrine syringes have been a problematic example over the last five or so years. More often than not, we are able to quickly pivot to other alternatives, and we can be ready at a moment’s notice to do so. 

Specific to EMS, you’ll find many examples of alternative drug options throughout the protocol in the event of a drug shortage. One example of this can be found in the Acute Coronary Syndrome protocol. Here we find two examples of alternative agents available, the first is diazepam (Valium) in place of midazolam (Versed) or lorazepam (Ativan).  The second is morphine as a backup to fentanyl. In these situations, you’ll find the dosing information in the Medication Section of the protocol rather than within the algorithm itself. This preparation helps us all to continue providing excellent care to our patients in the face of shortages.

Stickers to alert of shortages

When working through drug shortages, communication is key. Part of what makes drug shortages difficult with the EMS boxes is how quickly drug availability changes as opposed to the turnover of the EMS boxes. We may have a box out in the field for months on a squad that may not need to use drugs as often, or we may have a box out in the field for a day or less in between pharmacy refills on higher volume squads. The best way that we’ve found to communicate drug shortages is to place a brightly colored sticker on affected boxes to quickly alert you what has changed, whether it is fewer doses stocked in the box, a drug swap, or lack of a drug in the box. Due to the differences in how often boxes come back to the pharmacies, it is not uncommon for a squad to have one box affected by a drug shortage, and a different box not yet affected, or a newer box refilled once the shortage has ended. Following the hurricane in 2017, many drugs were affected in addition to the fluid bags. These include magnesium sulfate, sodium bicarbonate syringes, and epinephrine syringes – at times the drug boxes had two or more stickers alerting of changes. Fortunately, we are in a much better place with drug shortages today (fingers crossed I didn’t just jinx us).  

Drug shortages can be one of our biggest barriers to patient care, but we are well equipped to navigate these shortages as quickly and safely as possible. Through communication and preparation, we can all work together to maintain excellent patient care in the face of less-than-optimal resources.

Derek Frost, PharmD, MBA, BCPS