A Simulation-Based Root Cause Analysis of Pediatric Medication Dosing Errors in Emergency Medical Services

Area of Science:

• Emergency medicine
• Patient safety
• Human factors in healthcare

Background:

• Prehospital pediatric medication administration (PMA) has a persistent dosing error rate of approximately 31%.
• Previous research documented error characteristics but lacked understanding of underlying systemic causes.
• Identifying latent conditions within the emergency medical services (EMS) system is crucial for error reduction.

Purpose of the Study:

• To identify the root causes within the EMS system contributing to pediatric medication dosing errors.
• To understand the systemic vulnerabilities that lead to errors in prehospital pediatric medication administration.

Main Methods:

• A mixed-methods simulation-based study involving 11 EMS crews from two agencies.
• Simulated pediatric emergencies requiring medication administration, with recorded performance and post-simulation interviews.
• Root Cause Analysis and Action framework combined with a human factors framework to identify and categorize latent conditions.

Main Results:

• Latent conditions contributing to PMA errors were identified across all five tiers of the human factors framework.
• Identified conditions include individual factors (experience, stress), work nature (complexity, teamwork), human-system interface (usability), management (training), and external environment (protocols, technology).
• Errors are confirmed to arise from systemic issues rather than solely individual clinician actions.

Conclusions:

• Significant systemic vulnerabilities within EMS contribute to pediatric medication dosing errors.
• Addressing these identified latent conditions requires comprehensive strategies to improve PMA safety.
• Reducing PMA dosing errors necessitates a systemic approach focusing on improving EMS infrastructure and practices.