Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study.
Anaphylaxis
Autoinjector
Epinephrine
Medication error
Simulation
Journal
The journal of allergy and clinical immunology. In practice
ISSN: 2213-2201
Titre abrégé: J Allergy Clin Immunol Pract
Pays: United States
ID NLM: 101597220
Informations de publication
Date de publication:
04 2020
04 2020
Historique:
received:
01
06
2019
revised:
01
11
2019
accepted:
05
11
2019
pubmed:
27
11
2019
medline:
15
5
2021
entrez:
27
11
2019
Statut:
ppublish
Résumé
Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported. To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors. A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected. Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid. A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.
Sections du résumé
BACKGROUND
Multi-institutional, international practice variation of pediatric anaphylaxis management by health care providers has not been reported.
OBJECTIVE
To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions, including frequency and types of medication errors.
METHODS
A prospective, observational, study using a standardized in situ simulated anaphylaxis scenario was performed across 28 health care institutions in 6 countries. The on-duty health care team was called for a child (patient simulator) in anaphylaxis. Real medications and supplies were obtained from their actual locations. Demographic data about team members, institutional protocols for anaphylaxis, timing of epinephrine delivery, medication errors, and systems safety issues discovered during the simulation were collected.
RESULTS
Thirty-seven in situ simulations were performed. Anaphylaxis guidelines existed in 41% (15 of 37) of institutions. Teams used a cognitive aid for medication dosing 41% (15 of 37) of the time and 32% (12 of 37) for preparation. Epinephrine autoinjectors were not available in 54% (20 of 37) of institutions and were used in only 14% (5 of 37) of simulations. Median time to epinephrine administration was 95 seconds (interquartile range, 77-252) for epinephrine autoinjector and 263 seconds (interquartile range, 146-407.5) for manually prepared epinephrine (P = .12). At least 1 medication error occurred in 68% (25 of 37) of simulations. Nursing experience with epinephrine administration for anaphylaxis was associated with fewer preparation (P = .04) and administration (P = .01) errors. Latent safety threats were reported by 30% (11 of 37) of institutions, and more than half of these (6 of 11) involved a cognitive aid.
CONCLUSIONS
A multicenter, international study of simulated pediatric anaphylaxis reveals (1) variation in management between institutions in the use of protocols, cognitive aids, and medication formularies, (2) frequent errors involving epinephrine, and (3) latent safety threats related to cognitive aids among multiple sites.
Identifiants
pubmed: 31770652
pii: S2213-2198(19)30952-3
doi: 10.1016/j.jaip.2019.11.013
pii:
doi:
Substances chimiques
Epinephrine
YKH834O4BH
Types de publication
Journal Article
Multicenter Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
1239-1246.e3Investigateurs
Joo Lee Song
(J)
Robyn Wing
(R)
Susan Teman
(S)
Antonio Rodriguez-Nunez
(A)
Carisa Schneider
(C)
Danielle Mercurio
(D)
Christie Gutierrez
(C)
Michelle Gaba
(M)
Benny L Joyner
(BL)
Elizabeth S Vukin
(ES)
Jared Henricksen
(J)
Lynda Knight
(L)
Trish Wood
(T)
Renee England
(R)
Christina Cochran
(C)
Caroline Andler
(C)
Jennifer Muñoz-Pareja
(J)
Anja Grosse Lordemann
(AG)
Elizabeth Biddell
(E)
Informations de copyright
Copyright © 2019 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.