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Emergency Care for Children: Growing Pains
to anyone (Fairbanks and Crittenden, 2006). In another small study, which tested the ability of 14 paramedics to use a manual defibrillator, several paramedics defibrillated when they intended to cardiovert. This is a potentially fatal error, and in some cases, participants were not aware they had made the mistake. The researchers attributed the error to the defibrillators’ poor interface design (Fairbanks, 2004; Fairbanks et al., 2004).
However, the best evidence of medical errors and compromised safety concerns medication errors and adverse drug events in children. Prescribing errors occur more frequently in the ED than in any other part of the hospital and more frequently in the care of children than in that of adults. Medication errors were the most commonly reported type of error at one pediatric ED (Selbst et al., 1999). In a retrospective study of more than 1,500 charts of children treated in a pediatric ED, prescribing errors were identified in 10 percent of the charts (Kozer et al., 2002). These errors occurred more frequently during overnight hours (8:00 PM to 4:00 AM) and on weekends and were made most often by trainees. Another study evaluated medication errors with respect to antipyretics and found that 22 percent of acetaminophen doses ordered were outside the recommended 10–15 mg/kg/dose (Losek, 2004). Another study of medication errors among acutely ill and injured children presenting to rural EDs revealed errors in 48 percent of patient charts (Marcin et al., 2005). More seriously ill children are more likely to experience a prescribing error than those with less serious illnesses or injuries (Kozer et al., 2002).
Not surprisingly, the limited evidence available also indicates that medication errors occur frequently in the EMS environment. In a study that assessed the medication calculation skills of 109 paramedics, overall performance was found to be poor. On average, the paramedics answered 51 percent of the test questions correctly. Medication infusions were calculated incorrectly in one-third of cases (Hubble and Paschal, 2000; Fairbanks, 2004).
Challenges Associated with Prescribing and AdministeringMedications to Children in an Emergency Setting
Perhaps the foremost problem associated with providing medications to children is that many medications are frequently prescribed for children “off label,” meaning they have not been approved for pediatric use by the Food and Drug Administration (FDA). Once a drug has been approved for use by the FDA, further studies to determine its safety and efficacy in infants and children are rarely conducted for the majority of drugs (Rapkin, 1999). The result is that emergency providers must prescribe medications to children without a full understanding of the risks, benefits, or implications.