Dosing Errors Made by Paramedics During Pediatric Patient Simulations After Implementation of a State-Wide Pediatric Drug Dosing Reference

Prehosp Emerg Care. 2020 Mar-Apr;24(2):204-213. doi: 10.1080/10903127.2019.1619002. Epub 2019 Jun 10.


Background: Drug dosing errors occur at a high rate for prehospital pediatric patients. To reduce errors, Michigan implemented a state-wide pediatric dosing reference (PDR), with doses listed in milliliters, the requirement that doses be drawn into a smaller syringe from a pre-loaded syringe using a stopcock, and dilution of certain drugs to different concentrations.Purpose: To evaluate the rate of medication errors, including errors of omission and commission, after implementation of a state-wide PDR.Methods: EMS crews from 15 agencies completed 4 validated, simulation scenarios: an infant seizing, an infant cardiac arrest, an 18-month-old with a burn, and 5-year-old with anaphylactic shock. Agencies were private, public, not-for-profit, for-profit, urban, rural, fire-based, and third service. EMS crews used their regular equipment and were required to carry out all the steps to administer a drug dose. Two evaluators scored crew performance via direct observation and video review. An error was defined as [Formula: see text]20% difference compared to the weight-appropriate dose. Descriptive statistics were utilized.Results: A total of 142 simulations were completed. The majority of crews were (58.3%) Emergency Medical Technician-Paramedic (EMTP)/EMTP. For the cardiac arrest scenario, 51/70 (72.9%; 95% CI: 60.9%, 82.8%) epinephrine doses were correct. There were 6 (8.6%, 95% CI: 2.0%, 15.1%) 10-fold overdoses and one (1.4%; 95% CI: -1.4%, 4.2%), 10-fold under dose. In the seizure scenario, 28/50 (56.0%; 95% CI: 42.2%, 69.8%) benzodiazepine doses were correct; 6/18 (33.3%; 95% CI: 11.5%, 55.1%) drug dilutions were incorrect resulting in dosing errors. Unrecognized air was frequently entrained into the administration syringe resulting in under doses. Overall, 31.2% (95% CI: 25.5%, 36.6%) of drug doses were incorrect. Obtaining an incorrect weight led to a drug dosing error in 18/142 (12.7%, 95% CI: 7.2%, 18.2%) cases. Errors of omission included failure to check blood sugar in the seizure scenario and failure to administer epinephrine and a fluid bolus in anaphylactic shock.Conclusion: Despite implementation of a PDR, dosing errors, including 10-fold errors, still occur at a high rate. Errors occur with dilution and length-based tape use. Further error reduction strategies, beyond a PDR and that target errors of omission, are needed for pediatric prehospital drug administration.

Keywords: adverse drug events; drug dosing; medication errors; patient safety; pediatric.

Publication types

  • Observational Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Allied Health Personnel
  • Anaphylaxis / therapy
  • Body Weight
  • Burns / therapy
  • Child
  • Child, Preschool
  • Emergency Medical Services*
  • Epinephrine / administration & dosage*
  • Female
  • Heart Arrest / therapy
  • Humans
  • Infant
  • Male
  • Medication Errors*
  • Michigan
  • Patient Simulation
  • Seizures / therapy
  • Syringes
  • Vasoconstrictor Agents / administration & dosage*


  • Vasoconstrictor Agents
  • Epinephrine