Prevalence of Errors in Anaphylaxis in Kids (PEAK): A Multicenter Simulation-Based Study

Area of Science:

• Pediatric Emergency Medicine
• Patient Safety
• Healthcare Systems Analysis

Background:

• International practice variation in pediatric anaphylaxis management is not well-documented.
• Understanding this variation is essential for improving care quality.

Purpose of the Study:

• To characterize variability in epinephrine administration for pediatric anaphylaxis across institutions.
• To identify the frequency and types of medication errors during anaphylaxis management.

Main Methods:

• A prospective, observational study using standardized in situ simulated anaphylaxis scenarios.
• Simulations conducted across 28 healthcare institutions in 6 countries involving on-duty teams.
• Data collected on team demographics, institutional protocols, epinephrine timing, medication errors, and safety issues.

Main Results:

• Anaphylaxis guidelines were present in only 41% of institutions; cognitive aids were used infrequently for medication dosing (41%) and preparation (32%).
• Epinephrine autoinjectors were unavailable in 54% of sites and used in only 14% of simulations.
• Medication errors occurred in 68% of simulations, with nursing experience associated with fewer errors. Latent safety threats were identified in 30% of institutions.

Conclusions:

• Significant institutional variation exists in pediatric anaphylaxis management, including protocol use, cognitive aids, and medication availability.
• Frequent errors involving epinephrine administration and latent safety threats highlight critical areas for improvement.
• Enhancing protocols, ensuring autoinjector availability, and optimizing cognitive aid use are vital for safer pediatric anaphylaxis care.