Pediatric Drug Safety System

August 8, 2023

Welcome back to UH EMS-I’s Pharmacy Phriday! In this installment, we address medication errors in the pediatric population. It is reported by Johns Hopkins and the Journal of Patient Safety that medical errors are the third leading cause of death in the United States. Medication administration or dosing errors is a major concern when discussing medical errors, and important in all patient populations. However, it is estimated that critical dosing errors are three times more likely to occur in children than adults. “Roughly 7,000 kids die each year from medical dosing errors. The healthcare industry recognizes that we have a problem…” commented Dr. Hernandez.[1]

Prevention strategies instituted in EMS have included the use of length-based tapes and other guides and charts. But even with these aids, errors still occur. Factors that can contribute to dosing errors include the incorrect use of such length-based tapes. When measuring, the provider must be sure to measure from the top of the patient’s head to the heel. Additionally, squads must be sure to provide the most up-to-date version of the tool. 

Other factors leading to errors can include estimation of weight without these aids, incorrect calculation of weight-based doses, conversion of the doses in milligrams to milliliters, use of improper concentrations of a medication, and unrecognized air entrained into the administration syringe resulting in under doses. Additionally, these types of calls are high-stress, which can cause mental errors. Resuscitations in pediatrics are uncommon, and despite pediatric-specific guidelines, pediatric cardiac arrests have poor outcomes.

Another tool available to the UH provider in their drug boxes is the Certa Dose® PALS Syringe holder kit. This system was developed by a physician following a near-miss call during a resuscitation. The system can be used by the provider as an aid (the provider is still responsible to follow PALS guidelines and protocols during the arrest) in administering some of the most common resuscitation drugs for pediatric arrest. The kit includes 5 syringe holders (3 for use with Epinephrine 0.1mg/ml; 1 for use with Atropine 0.1mg/ml; 1 for use with Lidocaine 20mg/ml), baseline reference labels, a length-based tape, and instructions. 

A 2015 study looked at the frequency of errors with the use of such a system, as mentioned above. The conclusion from that study indicated, “A novel color-coded, prefilled syringe decreased time to medication administration and significantly reduced critical dosing errors by paramedics during simulated prehospital pediatric resuscitations.” (https://pubmed.ncbi.nlm.nih.gov/26247145/)

As providers, it is imperative we strive for excellence and accuracy in our treatments. Use of the Certa-Dose® PALS Syringe holder kit is a tool the provider should use to help assure proper medication dosing in the stressful circumstances of a pediatric arrest. For a video demonstration of the use of this product, follow this LINK to the manufacturer’s site


Till next week, stay safe!

[1] https://www.ems1.com/ems-products/ambulance-disposable-supplies/press-releases/certadose-wins-johnson-johnson-innovation-award-for-advancing-safety-in-healthcare-QzEJUNW23FZRXKSl/