ABSTRACT
Background: Pediatric drug dosing errors occur at a high rate in the prehospital environment. Objective: To describe paramedic training and practice regarding pediatric drug administration, exposure to pediatric drug dose errors and safety culture among paramedics and EMS agencies in a national sample. Methods: An electronic questionnaire was sent to a random sample of 10,530 nationally certified paramedics. Descriptive statistics were calculated. Results: There were 1,043 (9.9%) responses and 1,014 paramedics met inclusion criteria. Nearly half (43.0%) were familiar with a case where EMS personnel delivered an incorrect pediatric drug dose. Over half (58.5%) believed their initial paramedic program did not include enough pediatric training. Two-thirds (66.0%) administered a pediatric drug dose within the past year. When estimating the weight of a pediatric patient, 54.2% used a length-based tape, while 35.8% asked the parent or guardian, and 2.5% relied on a smart phone application. Only 19.8% said their agency had an anonymous error-reporting system and 50.7% believed they could report an error without fear of disciplinary action. For solutions, 89.0% believed an EMS-specific Broselow-Luten Tape would be helpful, followed by drug dosing cards in milliliters (83.0%) and changing content of standardized pediatric courses to be more relevant (77.7%). Conclusion: This national survey demonstrated a significant number of paramedics are aware of a pediatric dosing error, safety systems specific to pediatric patients are lacking, and that paramedics view pediatric drug cards and eliminating drug calculations as helpful. Pediatric drug-dosing safety in the prehospital environment can be improved.
Introduction
Pediatric prehospital drug-dosing errors occur at a high rate.Citation1–6 Multiple studies have demonstrated an error rate >30% for all drugs administered with an error rate for epinephrine doses of >60%.Citation1,4,6,7 In the hospital setting, drug dosing errors in pediatric patients have been shown to cause harm and even death.Citation8,9 Although much attention has been paid to medical errors in the hospital setting, there is a paucity of data regarding errors in the prehospital environment.Citation1,Citation5–7,Citation10–12
At the national level, a minimal amount is known regarding the magnitude or causes of pediatric prehospital drug dosing errors and even less has been done to correct this significant patient safety problem. Based on prior research, prehospital drug dosing errors affect approximately 56,000 U.S. children each year.Citation1 The prehospital practice of medicine by paramedics (EMT-Ps) frequently occurs in a chaotic and austere environment with none of the ancillary support found in a hospital. It is carried out by EMT-Ps whose training and licensure requirements vary greatly from state to state, and whose initial and continued pediatric training requirements are minimal.Citation13 Prehospital protocols often vary significantly between Emergency Medical Service (EMS) agencies, and have variable direct and indirect physician oversight.Citation13,14 These protocols require calculations of drug doses. Since pediatric cases are relatively uncommon, paramedics have minimal opportunities to gain experience and maintain competence in this skill. Based on data from 26 states contributing data to the National Emergency Medical Services Information System (NEMSIS), paramedics in those states delivered epinephrine 50,352 times to adults 18 and older but only 1,829 times to children 17 years and younger (3.5% of total administrations).Citation15 For dextrose, a drug that involves a very complex dose calculation, administration to children 17 years and younger occurred in just 0.8% of the total administrations.Citation15 The aforementioned factors make pediatric dosing errors more likely in the prehospital environment, increasing the risk of patient harm. Likewise, these factors demonstrate the need for patient safety systems, few of which are currently available in this environment.
We aimed to gain a better understanding of the current prehospital practice for administering drug doses to children and the factors affecting drug dosing throughout the United States. Utilizing a survey, we sought to describe training and practice related to pediatric drug administration, exposure to pediatric drug dose errors and the culture of safety among paramedics and EMS agencies in a sample of nationally certified paramedics.
Methods
Study Population and Design
This study was approved by the Bronson Health System IRB, Kalamazoo, MI with a waiver of written informed consent. A Federal Certificate of Confidentiality was obtained for the study, which protects study data from legal discovery. Participants were informed of this protection.
This was a cross-sectional analysis involving nationally certified paramedics from the National Registry of Emergency Medical Technicians’ (NREMT) database. At the time of sample selection, the NREMT database contained records for approximately 82,000 nationally certified paramedics. Paramedics were included if they were currently practicing and worked for at least one EMS organization. Military paramedics were excluded due to the homogeneity of their protocols and practice that differs greatly from that of civilian paramedics.
Survey questions were developed based on prior research related to prehospital medication dosing errorsCitation1,7 and responses from focus groups of EMT-Ps and EMS Medical directors held in Michigan.Citation5 Questions focused on the following areas: demographics and employment characteristics (age, years of EMS experience, community size, and type of EMS agency); pediatric training (frequency and content); confidence in caring for, calculating, and administering drug doses to pediatric patients; methods used to determine pediatric patient weight; potential solutions to make pediatric drug dosing more accurate; knowledge of an incorrect dose of medication being delivered to a pediatric patient; drug packaging; the culture of safety regarding pediatric patients; and use of the Broselow-Luten Tape (BLT). The BLT was selected since it is one of the oldest and most established emergency dosing aids.
Survey questions and format were cognitively debriefed with 10 practicing paramedics to assess readability and interpretation of the items prior to deployment with the selected sample. Based on the results of the cognitive debriefs changes were made to the question content and format. Finally, the survey was also reviewed by a survey methodologist prior to dissemination.
To determine the number of subjects needed for this study, a sample size calculation was performed assuming a 5% margin of error and a conservative 50/50 split. This determined that a sample of at least 383 nationally certified paramedics would be needed to make estimates with 95% confidence. Based on this calculation and assuming a low response rate, we utilized a random sample of 10,530 paramedics.
Data Collection and Analysis
EMT-Ps in the sample received a recruitment e-mail explaining the project and their rights as a participant. The email contained a URL link that to the online questionnaire. Following the Dillman approach, EMT-Ps in the sample who did not respond to the initial e-mails received reminder e-mails at one week and two weeks after the initial recruitment e-mail.Citation16 Data were collected utilizing Snap 10 Survey software (Snap Surveys, Portsmouth, NH). Results were exported into a Microsoft Excel spreadsheet (version 2013, Microsoft Corp., Redmond, OR) and were stored on secure servers at the NREMT office. Data in the analytic file did not contain identifiers such as names, addresses, or identifying numbers.
All statistical analyses were conducted using STATA/IC 12 (STATA Corporation College Station, TX) to produce mean and medians for each item with confidence intervals.
Results
Of 10,530 nationally certified paramedics in the sample 1,043 (9.9%) completed surveys and 1,014 (97.2%) met inclusion criteria. Table shows the demographic and employment characteristics of survey participants. The majority worked for fire-based services (38.7%) followed by private services (29.3%). Forty-one percent of respondents indicated that they have a paramedic partner. About one-third had less than five years of EMS experience (32.8%) while 27.7% reported having worked in EMS more than 15 years; most worked in urban communities of 25,000 or more residents (69.9%). The employment characteristics of the respondents in our study were similar to those of the population of nationally certified paramedics.Citation17
Table 1. Demographics of survey participants
Figure 1. Confidence of nationally-certified paramedics calculating correct pediatric medication doses by age group.
Exposure to Pediatric Drug Dose Errors and Patients Requiring Drugs
When respondents were asked if they were familiar with a case where a pediatric patient had received an incorrect dose of medication 42.8% responded “Yes.” When asked if they get enough pediatric exposure to maintain proficiency, respondents stated: strongly agree (6.3%), agree (22.0%), undecided (24.1%), disagree (38.6%), and strongly disagree (9.0%). Table shows the time since participants last administered a drug to a pediatric patient. Figure shows respondents’ level of confidence for calculating drug doses based on patient age. A significantly larger proportion of respondents felt “absolutely confident” calculating correct drug doses for adolescents (26.8%, 95% CI: 23.9%–29.6%) compared to school-aged children (16.5%, 95% CI: 14.2%–18.9%), toddlers (13.1%, 95% CI: 11.0%–15.3%), or infants (12.0%, 95% CI: 10.0%–14.1%).
Pediatric Training
Table displays responses regarding pediatric training and confidence in drug calculation and delivery skills on the day of completion of their last pediatric training course (e.g., Pediatric Advanced Life Support (PALS), Pediatric Education for Prehospital Providers (PEPP)).Citation18,19 Over half (58.1%) believed that their initial paramedic education course did not contain enough pediatric-specific training. Most respondents had taken a pediatric training course within the past 12 months (77.1%) and most reported that pediatric training was mandated by their agency (72.2%). The majority of paramedics (54.3%) reported that they were either “very confident” or “absolutely confident” calculating pediatric doses and delivering pediatric doses (57.8%) on the day they completed a pediatric training course.
Table 2. Time since last pediatric drug administration and last pediatric training course for survey participants
Obtaining Pediatric Patient Weight
The most frequent methods to obtain a pediatric patient's weight were using a length-based tape (54.7%), asking the parent/guardian (35.5%) and “I don't get a weight, I just give a smaller dose” (35.5%). Using a smart phone app (2.3%), “Do my best to guess the weight” (2.3%), using a formula based on age (2.2%), using a wheel device (1.2%) and “comparing the child to a child whose weight I know” (1.1%) were others methods used to determine weight. These percentages sum to greater that 100 because respondents were able to indicate more than one response.
Regarding BLT use, 85.1% of respondents stated they had access to one “always” or “frequently,” while 6.6% had access “occasionally.” Those with access to the BLT “rarely” or “never” were 8.3%. Sixteen percent of respondents stated they could not access the BLT without unlocking an equipment bag. When asked how frequently they use the BLT on pediatric patients, 29.3% stated “always,” 28.9% stated “frequently,” 22.9% stated “occasionally,” 17.0% stated “rarely,” and 2.0% stated “never.” When asked about BLT ease of use, 43.0% stated it was “very easy,” 51.7% stated it was “easy,” 5.1% stated it was “difficult,” and 0.1% stated it was “very difficult.”
Patient Safety Culture
Nearly one-third (31.1%) of participants reported that they have received no training related to patient safety (common mistakes and how to avoid them, team communication and accountability, etc.) from their EMS agency. Eighty percent of respondents stated their EMS system did not have an anonymous error reporting system. When asked if they could report an error without fear of disciplinary action the responses were: strongly agree (16.1%), agree (34.2%), undecided (24.2%), disagree (14.7%), strongly disagree (10.7%). Respondents, when asked if their agency distributed information about errors, stated this occurred: always (6.5%), frequently (14.5%), occasionally (24.5%), rarely (26.4%), and never (28.1%). Paramedics indicated that they have someone else check their drug calculations: always (29.9%), frequently (27.6%), occasionally (19.0%), rarely (14.9%), and never (8.7%). Finally, when asked about the amount of importance their agency places on pediatric patient safety, the responses were: too much importance (2.4%), more than adequate importance (36.7%), adequate importance (38.4%), some importance (17.9%), and no importance (4.6%).
Table 3. Variables that paramedics stated would be “very helpful” or “helpful” in decreasing pediatric drug dosing errors
Factors to Reduce Pediatric Drug-Dosing Errors
We also asked respondents about potential solutions that could be helpful in decreasing drug dosing errors. Drug packaging was indicated as causing problems with pediatric drug dosing: always (3.0%), frequently (12.3%), occasionally (39.9%), rarely (30.9%), and never (13.9%). Table lists the factors that respondents stated would be would be helpful/very helpful in reducing errors.
Discussion
Exposure to Pediatric Drug Dose Errors and Patients Requiring Drugs
This study of a national sample demonstrated that nearly half of paramedic respondents knew of a pediatric patient that had received an incorrect drug dose. This number may represent the “tip of the iceberg,” as previous studies have shown that errors are under reported.Citation20–22 Because doses for children must be calculated, children are at greater risk for dosing errors.Citation8,9,23,24 Fewer than one third of respondents agreed or strongly agreed that they get enough pediatric patient exposure to maintain proficiency. Given the number of pediatric encounters shown in previous studies it is surprising that this number was not even lower.Citation1,6 This result is contradictory to the high confidence level paramedics expressed regarding drug calculation and delivery.
Large percentages of respondents felt “confident” to “absolutely confident” in calculating and delivering drug doses to pediatric patients. These numbers were as high as 74.9% for infants and 87.2% for school-aged children (Figure ). There was a trend for respondents to feel more confident the older the pediatric patient was. This is surprising given the bimodal pediatric population paramedics actually encounter with the greatest subgroups being children less than 3 years and adolescents.Citation1 Toddlers and school aged children are actually encountered much less frequently than the aforementioned groups.Citation1 It could be that paramedics view and treat older children as adults and give standard adult doses that do not require calculation.
Examination of an EMS database in one state found that 71.5% of paramedics did not administer a drug to a pediatric patient over a 27-month period.Citation1 Contrary to this, 66.2% of paramedics participating in this survey indicated that they had administered a pediatric drug dose in the last 12 months. Given the infrequency of pediatric drug delivery in objective studies, this discrepancy may be explained by recall bias. If this bias exists, it could result in paramedics having greater confidence in their pediatric dosing skills than is justified, which could further contribute to errors.
Pediatric Training
Consistent with other research, the majority of paramedics expressed that pediatric training in their initial paramedic program was not enough.Citation5 This is concerning since pediatric encounters are infrequent for paramedics, making adequate training, both initial and continuing, more important. This leaves the paramedic reliant on themselves or their agency to obtain pediatric training. While the majority of paramedics (72.2%) indicated that their agency requires a pediatric-specific course such as PALS or PEPP and most (77.1%) indicated that they had taken that course in the last 12 months, only 57% indicated that their agency requires other pediatric training. This would suggest that a significant proportion of agencies appear to rely on PALS or PEPP as the only source of pediatric training. A majority of respondents to this survey (77.6%) stated that changing the content of pediatric courses (PALS/PEPP) to be more relevant to paramedic practice would be helpful in decreasing dosing errors. Recent research has also indicated that many paramedics do not view PALS and PEPP as helpful or relevant to their practice and the quality of instruction can be variable, from stringent to “if you show up you pass the course.”Citation5 They also had concerns that there was minimal instruction on pediatric drug dosing.Citation5 All of this suggests that improving the content of these courses to include more field-relevant material and practice on pediatric drug calculation/dosing needs to be made when the students are paramedics. Further study on skill retention and rate of decay from these courses is needed. A prior simulation study showed significant error rates despite the paramedic participants all having had PALS in the six months prior to the study.Citation10
Obtaining Pediatric Patient Weights
An accurate weight is the first step in delivering an accurate drug dose. Paramedics indicated that they use many methods to obtain weights of pediatric patients, with the most frequently used method being a length-based tape. Despite that, only 29.3% stated that they used a length-based tape “always” with a similar percentage indicating they use it “frequently.” Although 95% of paramedics rated use of the BLT as “easy” or “very easy,” prior studies have shown that errors are made frequently when using it.Citation10,25–27 A substantial percentage indicated that they ask the parent for the patient's weight. A recent study has shown this to be fairly accurate, depending on the patient's age.Citation28 More than a third of respondents indicated that, “I don't get a weight, I just give a smaller dose.” This practice is hazardous and could result in incorrect doses, which may or may not result in harm.
Culture of Patient Safety
This survey indicated that the culture of patient safety in EMS still has room for improvement. Only 20% of respondents indicated their agency had an anonymous error reporting system, and only half felt as if they could report an error without fear of disciplinary action. Knowledge of and reporting errors, without fear of retribution, are critical to improving patient safety culture within EMS. Reported errors should trigger a review through the agency Continuous Quality Improvement (CQI) process to address system problems and processes without focusing on the individual provider. Distributing information, agency-wide, about errors that had occurred was an infrequent event. Information on errors is even more critical for pediatric patients who are at greater risk for medication dosing errors.Citation8,9,23–25 In contrast to the low rate of distribution of information on errors, 85% of respondents thought that their agency placed an adequate or greater emphasis on patient safety, yet only 69% stated they received formal patient safety training.
One specific patient safety behavior is having a separate person check your drug calculation and dose. Fifty-eight percent of respondents stated that they have someone check their calculations either always or frequently, yet only 41% of respondents indicated that they have a paramedic partner. This brings up two concerns. First, drug dose calculations and the dose itself should always be checked prior to administering medication to a pediatric patient. Second, if they are checking drug doses with someone who does not have drug calculations and delivery within their scope of practice, training and experience then the validity of that check is questionable.
Possible Solutions
We asked if specific safety measures would be helpful to reduce pediatric medication dosing errors. A Broselow-like tape specific for EMS, pediatric drug dosing cards with doses in milliliters, an EMS-specific smart phone pediatric app, eliminating calculations for drug dosing and doing weekly pediatric drug dosing problems were rated as helpful to very helpful by two thirds or more of respondents. The current BLT contains a large number of drugs and equipment that are not commonly used by EMT-Ps. A length-based tape with only prehospital drugs and equipment could decrease confusion and allow for larger print. Another issue with the current BLT is that most drug doses are listed in milligrams and still require a conversion calculation to arrive at the number of milliliters to deliver to the patient. Pediatric drug cards with doses listed in milliliters offer the elimination of drug calculations, which many paramedics find difficult and error-prone.Citation5,29 If pediatric drug calculations are to remain a part of paramedic practice, regular practice is needed to hone this skill. Although two-thirds of paramedics in this survey stated they had given a drug to a child in the last 12 months, prior research has shown that a large percentage of paramedics may not administer a drug to a pediatric patient for 24 months or longer.Citation1 It is possible this high percentage was due to recall bias, with the real percentage being lower. Also, with such little experience and infrequent training, it is unreasonable to expect paramedics to calculate and administer drug doses for children without a high rate of errors.
Surprisingly, only half of paramedics thought a daily pediatric equipment checklist would be helpful. Checklists have been shown to decrease errors in other settings.Citation30–32 This may reflect that pediatric equipment is not typically involved in medication dosing; however, familiarity with the BLT, drug dosing cards and pediatric equipment would be helpful.
Other interventions felt to be the least helpful in reducing medication errors were: taking a pediatric course (PALS/PEPP) every 6–12 months, having the pediatric patient's weight from dispatch and communication with a physician for drug doses. Although one would expect that more frequent training would improve performance and decrease errors, prior research has indicated that paramedics having had PALS in the last six months, and brief refresher training every 1–4 months after that, still had a high drug dosing error rate.Citation10 This may also reflect the paramedics’ assessment that these training courses are not helpful to their practice. Having a pediatric patient's weight en route to a call would allow more time to consult references or to do drug calculations. Paramedics have indicated a certain level of mistrust for information obtained from dispatch.Citation5 This likely is not due to the dispatchers themselves, but the information the dispatchers are able to obtain from emotionally distraught 9-1-1 callers. Finally, only 44.3% of respondents viewed communication with a physician regarding drug doses as helpful or very helpful. Paramedics have expressed frustration in radio communication with physicians for medication orders or assistance with calculations. The level of training of the physician, the timeliness of the physician getting to the radio, the physician knowledge of EMS protocols and drugs, as well as the physician's likelihood of belaying drug administration by paramedics have been cited in prior research as barriers to effective radio communication with physicians.Citation5
More than 56% of paramedics stated drug packaging did cause problems for them in delivering accurate doses to children, either occasionally or more frequently. Prior research has demonstrated that drugs packaged for adult doses and frequent changes in drug suppliers, concentrations and number of milligrams per vial were concerns for paramedics delivering drug doses to pediatric patients.Citation5 Changing drug packaging to be more relevant for pediatric patients could be helpful instead of the current situation that requires all drugs be dosed from prefilled syringes and vials that contain adult doses.
Limitations
This study is limited by the typical issues surrounding survey research including bias due to misinterpretation and inaccurate reporting. To reduce ambiguity issues related to these biases, the survey was cognitively debriefed and an expert in survey methodology reviewed the final product. Respondents had as much time as needed to complete the survey. Some may not want to participate in a survey asking about patient safety for fear of reprisal. In order to protect anonymity of the respondents, no identifying information was collected and to further protect respondents, a Federal Certificate of Confidentiality was obtained. All of this information was conveyed to the respondents at the beginning of the survey. Although we did have a low return rate, we utilized a large national sample and had more than two and a half times the sample size to reach 95% confidence.
Conclusion
This national survey demonstrated a significant number of paramedics are aware of pediatric dosing error, safety systems specific to pediatric patients are lacking, and that paramedics view specific safety measures such as pediatric drug cards, and eliminating drug calculations as helpful. Significant progress needs to be made in improving pediatric patient drug-dosing safety in the prehospital environment.
IPEC_A_1227001_supplemental.docx
Download MS Word (36.7 KB)References
- Hoyle JDJr., Davis AT, Fales WD, Trytko JA, Putman KK. Medication dosing errors in pediatric patients treated by Emergency Medical Services. Prehosp Emerg Care. 2012;16(1): 59–66.
- Lammers RL, Byrwa M, Fales WD. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med. 2012;19(1):37–47.
- Lammers R, Willoughby-Byrwa M, Fales WD. Medication errors in prehospital management of simulated pediatric anaphylaxis. Prehosp Emerg Care. 2014;18(2):295–304.
- Lammers R, Willoughby-Byrwa M, Fales WD. Errors and error-producing conditions duirng a simulated, prehospital pedaitric cardiopulmonary arrest. Simul Healthcare. 2014;9(3):174–83.
- Hoyle Jr. JD, Sleight D, Henry R, et al. Pediatric prehospital medications dosing errors: A mixed methods study. Prehosp Emerg Care. 2016;20(1):117–24.
- Kaji AH, Gausche-Hill M, Conrad H, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493–500.
- Lammers RL, Byrwa MJ, Fales WD, Hale RA. Simulation-based assessment of paramedic pediatric resuscitation skills. Prehosp Emerg Care. 2009;13(3):345–56.
- Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse events in pediatric inpatients. JAMA. 2001;285(16):2114–20.
- Wong ICK, Ghaleb MA, Franklin BD, Barber N. Incidence and nature of dosing errors in paediatric mediciations. Drug Saf. 2004;27(9):661–70.
- Lammers RL, Byrwa MJ, Fales WD. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med. 2012;19(1):37–47.
- Vilke GM, Marino A, Fisher R, Chan TC. Estimation of pediatric patient weight by EMT-Ps. J Emerg Med. 2001;21(2):125–8.
- Vilke GM, Tornabene S V, Stepanski B, et al. Paramedic self-reported medication errors. Prehosp Emerg Care. 2006;10:457–62.
- Emergency Medical Services at the Crossroads. Washington, DC: National Academies Press, 2007.
- Kuehl AE. Prehospital Systems and Medical Oversight, 3rd ed. Dubuque, IA: Wiley, 2002.
- Dai M. Personal Communication. National EMS Information Data Center, 2010.
- Dillman DA, Smyth JD CL. Internet, mail, and mixed-mode surveys: The tailored design method. 3rd ed. Hoboken, NJ: Wiley, 2009.
- National Registry of Emergency Medical Technicians. 2014 National EMS Practice Analysis. Columbus, OH: National Registry of Emergency Medical Technicians, 2015.
- Chameides L, Samson RA, Schexnayder SM, Hazinski MF (eds.). Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association, 2010.
- American Academy of Pediatrics (AAP). Pediatric education for prehospital professionals (PEPP). Sudbury, MA: Jones & Bartlett Publishers, 2013.
- Flynn E, Barker K, Pepper G, Al E. Comparison of methods for detecting medical errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2003;59(5):436–46.
- Pham JC, Thiery G, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013;2(e27):154–9.
- Sari A, Sheldon T, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital:retrospective case note review. BMJ. 2007;334:79.
- Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: Implications for prevention. JAMA. 1995;274(1):29–34.
- Ghaleb MA, Barber N, Franklin BD, Yeung VWS. Systematic review of medication errors in pediatric patients. Ann Pharmacother. 2006;40:1766–76.
- Hoyle JDJr., Davis A, Putman KK, Trytko JA, Fales WD. Pediatric drug-dosing errors in Emergency Medical Services. Acad Emerg Med. 2008;15(5):S72.
- Hohenhhaus SM, Frush KS. Pediatric patient safety: Common problems in the use of resuscitative aids for simplifying pediatric emergency care. J Emerg Nurs. 2004;30(1):49–51.
- Morgan N, Luo X, Fortner C, Frush K. Opportunities for performnace improvement in relation to medication administration during pediatric stabiliaization. Qual Saf Health Care. 2006;15:179–83.
- Chassee T, Reischman D, Mancera M, Hoyle. JD. A novel approach utilizing emergency medical dispatchers to obtain weights on pediatric patients. Prehosp Emerg Care. 2014;18(1):150.
- Bernius M, Thibodeau B, Jones A, Clothier B, Witting M. Prevention of pediatric drug calculation errors by prehospital care providers. Prehosp Emerg Care. 2008;12:486–94.
- Anup K, Wade R, Neil F. Development of a strategic process using checklists to facilitate team preparation and improve communication during neonatal resuscitation. Resuscitation. 2013;84:1552–7.
- Conroy MJ, Weingart GS, Carlson JN. Impact of checklists on peri-intubation care in ED trauma patients. Am J Emerg Med. 2014;32:541–4.
- Kelleher DC, Carter EA, Waterhouse LJ, et al. Effect of a checklist on advanced trauma life support task performance during pediatric trauma resuscitation. Acad Emerg Med. 2014;21(10):1129–34.