| TITLE |
| Paediatric Resuscitation and Transfer Calculation Tool: Learning From Mistakes |
| BACKGROUND |
| A young infant presented to ……. requiring urgent resuscitation and stabilisation, including invasive ventilation. This was carried out mainly by ICU doctors in the Emergency Department. The local transfer team attended for transfer and noted a 10-fold calculation error in an ongoing infusion – this was quickly corrected and there was no actual patient harm. This was stressful and upsetting for all professionals and family involved, and identified the need for a safety tool to prevent recurrence of calculation error in similar future situations. |
| METHODS |
| A series of debriefs and teaching sessions with those directly involved or potential to be in future (i.e. Anaesthesia/ICU doctors and consultants) to identify the core issues. These revealed multiple contributory factors: stressful event, outside of the comfort zone/scope of usual practice for most doctors, in an unfamiliar ED environment where ED staff unfamiliar/under-trained in process of intubation/stabilisation, anaesthetic drugs and equipment. Furthermore, teaching sessions on paediatric critical care infusion guidelines showed they were error-prone, even in controlled and calm environments; this was demonstrated in both trainee and experienced consultant populations. This was partially attributed to the miniscule doses used, as well as some unfamiliar specialist drugs. |
| RESULTS |
| The ‘near miss’ event identified the need for a cognitive offloading tool, aimed at the non-paediatric specialist, to prevent further dosing errors born from miscalculation. The tool was developed such that non-ICU/anaesthetic professionals could also assist with drug and equipment preparation, and management. The tool is presented as A3, double sided flip-chart, available in theatres, intensive care and paediatric resuscitation rooms. It comprises sheets for Newborn-12 years, with additional weight increments either side of this range. Dose of drug to be added to syringe and infusion rate range are specified; emergency/intubation/common drugs and infusions included, as well as specialist cardiac/respiratory/neurological infusions. Also included are WETFLAG, airway and vascular access equipment sizes. It is laminated/wipeable/infection control friendly, colour-coded as per anaesthetic stickers, and fully referenced with up-to-date guidelines. |
| DISCUSSION |
| The tool was presented at local Morbidity & Mortality meeting, joint with Emergency Medicine colleagues, with immediate feedback incorporated. Calculations were verified by several anaesthetists and ICU pharmacist.It is currently being trialled in our hospital, with plans to offer it to the Trust, following incorporation of further feedback and improvements. |
| ACKNOWLEDGEMENTS |
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| REFERENCES |
| 1. Paediatric Critical Care Infusions V2.7 2021 2. Intersurgical. Paediatric Normal Values – Anaesthesia 2019 3. Skellet S, et al. Paediatric Advanced Life Support Guidelines. Resuscitation Council UK 2021.4. Alvo A, et al. Paediatric Nasopharyngeal Airways. Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery 2020; 9.5. Starship NZ. Nasogastric & nasojejunal tube care for an infant, child or young person. 2023. 6. Arrow. EZ-IO Intraosseus Vascular Access System 2023. |
