Avoiding errors when administering injectable phenytoin to a child in status epilepticus

Area of Science:

• Pharmacology
• Pediatric Nursing
• Patient Safety

Background:

• Intravenous phenytoin administration is associated with frequent errors in prescribing, preparation, administration, and monitoring.
• Two fatal incidents linked to injectable phenytoin highlighted issues like incorrect weight estimation, disregarded prescriptions, and concentration confusion, prompting an NHS Improvement alert in 2016.

Purpose of the Study:

• To explore research on injectable phenytoin use and the causes of adverse events.
• To inform healthcare professionals, particularly nurses and doctors working with children in acute settings, about the risks of injectable phenytoin.
• To provide implications for practice aimed at mitigating these risks.

Main Methods:

• Literature review of research on injectable phenytoin.
• Analysis of contributing factors to adverse events.
• Synthesis of findings to inform clinical practice.

Main Results:

• Identified common error points in the medication use process for intravenous phenytoin.
• Highlighted specific risk factors contributing to adverse events, including weight estimation errors and concentration misunderstandings.
• Emphasized the need for improved protocols and awareness among healthcare providers.

Conclusions:

• Understanding the risks associated with injectable phenytoin is crucial for preventing adverse events.
• Implementing evidence-based practices can lead to safer and more effective patient care.
• Continuous education and vigilance are necessary for healthcare professionals managing pediatric patients receiving intravenous phenytoin.