Epinephrine
Loren Bonner
Epinephrine can save lives during anaphylaxis, but it can also be confusing to administer. While medication errors involving epinephrine have been known to occur, researchers of a new study published in the Journal of Allergy and Clinical Immunology: In Practice sought to investigate how prevalent these errors were in pediatric patients and why they might be happening in the first place. According to lead study author Tensing Maa, MD, children are at an increased risk for medication errors because the correct dose varies based on the child’s weight.
Maa and colleagues conducted a prospective, observational study of 37 in situ simulated anaphylaxis scenarios that were standardized across 28 health care institutions in six countries. The on-duty health care providers were asked to respond to the simulated emergency and care for the child simulator in the actual clinical environment.
“There were low rates of institutions using either an anaphylaxis protocol, epinephrine autoinjector (EAI), or decision support aid,” said Maa, who is medical director of the simulation program at Nationwide Children’s Hospital in Columbus, OH.
According to the study findings, anaphylaxis guidelines existed in 41% of the institutions participating. Health care teams used decision support aids for medication dosing 41% of the time and 32% for preparation. EAIs were not available in 54% of participating institutions and were used in only 14% of the simulations.
“Some health care teams did not choose to use an EAI even though they were available at the hospital. This might be due to the team not knowing what resources are available,” said Maa. She added that errors still occurred when decision support aids were used, indicating that there are opportunites for improvement in the design of these tools.
Almost one-third of the sites identified system-level processes or human factor–related patient safety concerns as contributors to medication errors. “Institutions that discovered such errors had the opportunity to mitigate them before any patient was harmed,” said Maa.
Overall, Maa said she was surprised by the high medication error rate, which occurred even for well-trained health care teams.
EAIs as first-line therapy
At Johns Hopkins Hospital in Baltimore, where Meghan Rowcliffe, PharmD, BCPS, BCPPS, is pediatric medication safety officer, EAIs are first-line therapy for pediatric patients.
“We have had this practice in place for many years, and I truly believe having EAIs available for use in pediatrics has mitigated risk of significant harm, especially wrong-route errors, since the device prevents I.V. administration,” said Rowcliffe. To promote safety, they also have cognitive aids available for prescribing and administration, she added.
For Rowcliffe, the study highlighted the common epinephrine errors she’s familiar with—primarily errors in dose, route, and concentration.
Adding to the risk, Rowcliffe said, are the multiple forms of epinephrine available, dosing strategies, and routes of administration.
“Pharmacists should be empowered to respond to rapid response events such as anaphylaxis and be involved in facilitating correct prescribing and preparation of epinephrine for anaphylaxis,” she said.
The study was not designed to detect significant differences in error rates between manually drawn epinephrine compared with EAIs.
Pharmacists can help
Health-system pharmacists should consider EAIs in formulary decisions and even advocate for their use. Maa said pharmacists could limit the number of EAIs stocked but still approve them to the formulary.
“EAIs do have increased costs, and there is a risk of their expiring before being used,” she said. “However, anaphylaxis management can be a high-stress, time-dependent event. Having an EAI available versus drawing it up from a vial in such a situation could make a big difference.”
She suggested limiting the number of EAIs stocked in automated dispensing cabinets and refilling them when needed versus overstocking them and having them go to waste.
Pharmacists can review the clinical decision support aids at their institutions and make sure they are accurate and easy to use, as well as assist in developing the references and cognitive aids.