Care of suspected long bone fractures in the emergency department: Families' perspectives and priorities.

OBJECTIVE: Despite growing interests in patient-reported outcomes, youth and families are rarely involved in designing quality improvement measures. Few quality indicators exist for the care of children with injuries in the Emergency Department (ED) and extremity fractures are among the most common injuries in children. This study's aim was to identify both parents' and youth's perspectives about ED care in the context of a suspected long-bone fracture. METHODS: Youth (10-18 years old) and their parents were surveyed prospectively during their ED visit. Participants were asked: 1) to identify their main concerns, 2) to identify quality measures that were most important to them, and 3) to evaluate the ED care they received. Descriptive analyses present participants' responses. Continuous data was analyzed using a Student t-test and categorical data using a Chi-square test. RESULTS: Over 15 months, 350 families met eligibility criteria and were approached to participate, of which 300 participants consented and 249 surveys were completed (71% response rate): 148 parents and 101 youth (median age: 12) completed their respective surveys. Participants placed a high importance on several themes: pain management, short length of stay, and quality interactions with ED clinicians. Youth as a group prioritized their overall wellbeing and the ED environment (e.g., waiting room comfort, signage), while parents focused on accurate diagnoses and treatments. The following items were less prioritized: that radiology be close to the ED, to see the radiograph, to have access to a wheelchair, to know the identities of clinicians on the team, and to have access to entertainment. Parents and youth within the same family often did not share the same priorities. Ninety-two percent of parents reported their child's pain was treated, while 81% and 63% of youth reported their pain was treated sufficiently and quickly, respectively. CONCLUSIONS: Parents and youth can identify their priorities for ED care and should be engaged in efforts to improve and report on the quality of care in the ED. Youths' and parents' perspectives are complimentary and may not align, even within families. The priorities identified in this study can help inform quality improvement initiatives and personalized patient care.

Estimating the Weight of Children During Simulated Emergency Situations Using the Broselow Tape: Are We Underestimating the Risks of Errors?

OBJECTIVE: The objective of this study was to evaluate whether residents can accurately estimate children's weight using the Broselow tape. METHOD: We conducted a preplanned secondary analysis from an experimental trial. Participants were residents in pediatrics, family medicine, and emergency medicine rotating in the ED. Residents were randomly assigned to 2 sets of paired scenarios during 2 sessions. They were asked to estimate the weight of a manikin using the Broselow tape at the beginning of each scenario. The first scenario from the initial session and the last scenario from the second session were used for the current study. The primary analysis was the proportion of participants who accurately estimated manikin weight within a 10% margin of error. RESULTS: Forty residents were recruited. Thirty-two (80%) reported knowledge of the Broselow tape and 13 (32.5%) reported previous use. Weight estimation was accurate in 60% (24/40; 95% confidence interval [CI], 45%-74%) during the first scenarios. Error in weight estimation differed by greater than 25% in 28% (11/40). Error in estimation was not associated with previous knowledge (odds ratio, 6.2; 95% CI, 0.68-56) or previous use (odds ratio, 0.9; 95% CI, 0.23-3.5) of the Broselow tape. In the last scenario, 88% accurately estimated manikin weight (35/40; 95% CI, 73%-95%). CONCLUSIONS: Although most residents reported knowledge of the Broselow tape, 40% made erroneous weight estimations by at least 10% with the first use in this simulation study. With repeated use, they improved significantly over time. Teaching appropriate use of the Broselow tape should be part of residency-training curricula and pediatric advanced life support course.

Medication errors in the management of anaphylaxis in a pediatric emergency department.

BACKGROUND: Despite the publication of recent guidelines for anaphylaxis management, many studies show that physicians are still not at ease with the management of anaphylaxis. OBJECTIVES: To evaluate the rate and severity of medication errors before and after implementation of a standard order form for anaphylaxis management. METHODS: A before-and-after study was conducted. All children <18 years of age presenting to a tertiary care pediatric hospital Emergency Department with anaphylaxis between September 2007 and November 2010 were included. Patients were divided into two groups according to intervention (Pre and Post). Intervention consisted of the implementation of a standard order form (SOF) for anaphylaxis management. The post-intervention group was further sub-divided into SOF+ (when the SOF was used) and SOF- (when the SOF was not used). RESULTS: A total of 96 medical charts were reviewed. There were 31 patients in Pre and 65 in Post (29 in SOF+ and 36 in SOF-). A total of 243 drugs were ordered. Thirty-five percent (85/243) of these orders contained at least one medication error. Fifty-five percent (47/85) were dosage errors. The rate of medication errors was the same between Pre and Post (60% vs. 59%, p = 0.95). However, the rate of dosage errors was significantly reduced when the SOF was used (21% in SOF+ vs. 50% in Pre, p = 0.02 and 21% in SOF+ vs. 50% in SOF-, p = 0.02). CONCLUSIONS: Medication errors in the management of anaphylaxis were frequent. Use of an SOF significantly reduced the rate of dosage errors.

Quality of orders for medication in the resuscitation room of a pediatric emergency department.

OBJECTIVE: The aim of this study was to evaluate both the errors and completeness of orders for intravenous medications and fluids in the resuscitation/trauma room of a pediatric emergency department before and after implementation of a standard order form. METHODS: After implementing a standard order form in March 2004, a retrospective chart review of patients admitted to the resuscitation/trauma room of a pediatric tertiary care hospital in March, May, and July 2003 and, again in the same months 1 year later, in 2004. The completeness criteria were based on recommendations from the Institute for Safe Medication Practice and are the same as the ones used in our hospital. Medication errors and their severity were classified according to definitions of the American Society of Health-System Pharmacists. RESULTS: In the 3 months studied in 2003, 14 (5%) of 276 written orders fit the standard of completeness, whereas in the 3 months studied in 2004, 93 (33%) of 281 were complete. There were 55 (15%) medication errors of 372 orders in 2003 and 20 (6%) of 347 orders in 2004. Thus, during the 2 study periods, there was an increase in completeness (Delta 28%; 95% confidence interval, 22%-34%) and a decrease in medication errors (Delta 9%; 95% confidence interval, 5%-13%). Most of the errors had no adverse effects on patients. However, 11 errors (10 in 2003 and 1 in 2004) required some intervention. Most interventions resulted in the need for an additional dose of medication because of underdosage. CONCLUSIONS: A standard designated order form was associated with an increase in completeness and with a decrease in prescribing errors in the resuscitation/trauma room of a pediatric emergency department.

Decreasing Prescribing Errors During Pediatric Emergencies: A Randomized Simulation Trial.

OBJECTIVE: To evaluate whether a clinical aid providing precalculated medication doses decreases prescribing errors among residents during pediatric simulated cardiopulmonary arrest and anaphylaxis. METHODS: A crossover randomized trial was conducted in a tertiary care hospital simulation center with residents rotating in the pediatric emergency department. The intervention was a reference book providing weight-based precalculated doses. The control group used a card providing milligram-per-kilogram doses. The primary outcome was the presence of a prescribing error, defined as a dose varying by ≥20% from the recommended dose or by incorrect route. Residents were involved in 2 sets of paired scenarios and were their own control group. Primary analysis was the difference in mean prescribing error proportions between both groups. RESULTS: Forty residents prescribed 1507 medications or defibrillations during 160 scenarios. The numbers of prescribing errors per 100 bolus medications or defibrillations were 5.1 (39 out of 762) and 7.5 (56 out of 745) for the intervention and control, respectively, a difference of 2.4 (95% confidence interval [CI], -0.1 to 5.0). However, the intervention was highly associated with lower risk of 10-fold error for bolus medications (odds ratio 0.27; 95% CI, 0.10 to 0.70). For medications administered by infusion, prescribing errors occurred in 3 out of 76 (4%) scenarios in the intervention group and 13 out of 76 (22.4%) in the control group, a difference of 13% (95% CI, 3 to 23). CONCLUSIONS: A clinical aid providing precalculated medication doses was not associated with a decrease in overall prescribing error rates but was highly associated with a lower risk of 10-fold error for bolus medications and for medications administered by continuous infusion.