Improving Pediatric Medication Safety Through Implementation of Evidence-Based Guidelines

Pediatric medication dosing errors are common in the prehospital setting, particularly during high-acuity, low-frequency events requiring weight-based calculations. Evidence-based guidelines recommend standardized weight estimation, volume-based dosing, use of cognitive offload tools, and clinician training to reduce errors. We sought to implement these guidelines across an emergency medical services (EMS) system with the aim of ≥95% correct dosing for initial pediatric medication administration.

This quality improvement initiative was conducted amongst multiple agencies within a single EMS system serving upstate New York and guided by the Model for Improvement. Baseline dosing accuracy for patients aged ≤13 years was calculated using registry data from 2020-2022. Interventions included implementation of a protocol-integrated, volume-based dosing application; standardized length-based weight estimation; and case-based, hands-on training. Monthly performance was monitored using Shewhart p-charts to measure % correct dosing for all medications and using Individual (I) charts to measure the degree of variability from goal midazolam dosing for seizures. Ongoing case review was used to identify sources of error and inform iterative interventions, including targeted retraining and redesign of how medications were represented within the application.

Correct dosing at baseline from 2020-2022 was 79% overall, with substantial variability by medication. Midazolam for pediatric seizure was the most frequently incorrectly dosed medication at baseline (65% correct). Initial improvements were observed following implementation, with median correct dosing increasing to 91% beginning in Fall 2023. Subsequent protocol changes introduced new variation, particularly related to route-specific midazolam dosing. Targeted retraining and human-centered redesign of dose presentation within the application were associated with further improvement. Sustained process improvement to 97% correct dosing for all first-dose medications was achieved by December 2025.

Improving pediatric medication safety in EMS requires a comprehensive, collaborative, and iterative quality management approach. Sustained high performance was achieved through continuous monitoring, targeted intervention, and system-level collaboration, demonstrating that implementation of evidence-based tools must be paired with ongoing quality infrastructure to achieve reliable and durable improvement.