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

Area of Science:

• Pediatric Emergency Medicine
• Clinical Pharmacology
• Patient Safety

Background:

• Physicians often struggle with anaphylaxis management despite existing guidelines.
• Medication errors are a significant concern in pediatric anaphylaxis care.
• Standardized protocols may improve the safety and efficacy of anaphylaxis treatment.

Purpose of the Study:

• To assess medication errors in pediatric anaphylaxis before and after implementing a standard order form (SOF).
• To evaluate the impact of the SOF on the rate and severity of medication errors.
• To determine if a standardized approach improves anaphylaxis medication safety.

Main Methods:

• A before-and-after study design was employed in a pediatric Emergency Department.
• Included were children under 18 diagnosed with anaphylaxis between 2007 and 2010.
• Intervention involved implementing a standard order form (SOF) for anaphylaxis management, with post-intervention analysis comparing SOF use versus non-use.

Main Results:

• Overall medication errors occurred in 35% of 243 drug orders, with 55% being dosage errors.
• The rate of medication errors did not significantly change post-SOF implementation (60% vs. 59%).
• However, the rate of dosage errors significantly decreased with SOF use (21% with SOF vs. 50% without).

Conclusions:

• Medication errors, particularly dosage errors, are frequent in pediatric anaphylaxis management.
• The implementation of a standard order form (SOF) effectively reduced dosage errors.
• Standardized order forms represent a valuable tool for enhancing patient safety in anaphylaxis treatment.