A Mobile Device App to Reduce Time to Drug Delivery and Medication Errors During Simulated Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial

Abstract

Background: During pediatric cardiopulmonary resuscitation (CPR), vasoactive drug preparation for continuous infusion is both complex and time-consuming, placing children at higher risk than adults for medication errors. Following an evidence-based ergonomic-driven approach, we developed a mobile device app called Pediatric Accurate Medication in Emergency Situations (PedAMINES), intended to guide caregivers step-by-step from preparation to delivery of drugs requiring continuous infusion.

Objective: The aim of our study was to determine whether the use of PedAMINES reduces drug preparation time (TDP) and time to delivery (TDD; primary outcome), as well as medication errors (secondary outcomes) when compared with conventional preparation methods.

Methods: The study was a randomized controlled crossover trial with 2 parallel groups comparing PedAMINES with a conventional and internationally used drugs infusion rate table in the preparation of continuous drug infusion. We used a simulation-based pediatric CPR cardiac arrest scenario with a high-fidelity manikin in the shock room of a tertiary care pediatric emergency department. After epinephrine-induced return of spontaneous circulation, pediatric emergency nurses were first asked to prepare a continuous infusion of dopamine, using either PedAMINES (intervention group) or the infusion table (control group), and second, a continuous infusion of norepinephrine by crossing the procedure. The primary outcome was the elapsed time in seconds, in each allocation group, from the oral prescription by the physician to TDD by the nurse. TDD included TDP. The secondary outcome was the medication dosage error rate during the sequence from drug preparation to drug injection.

Results: A total of 20 nurses were randomized into 2 groups. During the first study period, mean TDP while using PedAMINES and conventional preparation methods was 128.1 s (95% CI 102-154) and 308.1 s (95% CI 216-400), respectively (180 s reduction, P=.002). Mean TDD was 214 s (95% CI 171-256) and 391 s (95% CI 298-483), respectively (177.3 s reduction, P=.002). Medication errors were reduced from 70% to 0% (P<.001) by using PedAMINES when compared with conventional methods.

Conclusions: In this simulation-based study, PedAMINES dramatically reduced TDP, to delivery and the rate of medication errors.

Keywords: biomedical technology; medication errors; pediatrics; pharmaceutical preparations; resuscitation.

Figure 1

Study design: A two-period, randomized controlled, two-arm crossover study.

Figure 2

PedAMINES screenshot. List of bolus IV drugs (white boxes) and drugs for continuous infusion (yellow boxes) are selectable in the left margin of the application. The right window shows drugs selected by the nurse for a ten kilograms child. In this screenshot example, epinephrine is being delivered at an infusion rate of 0.3 mcg/kg/min. Amiodarone is selected and ready to be injected, waiting for nurse’s confirmation. Dopamine is being prepared by the nurse following a descriptive and detailed path automatically calculated by the application. The printer logo in the upper right corner indicates that all actions performed by the nurses are sequentially saved in historic files that can be retrieved and printed at any time.

Figure 3

Patient flowchart for randomized controlled trial on preparation of continuous drug infusion by nurses in simulation-based pediatric cardio-pulmonary resuscitation cardiac arrest scenario.

Figure 4

Study period 1 (Dopamine) and 2 (Norepinephrine). Boxplots of elapsed time to drug preparation (TDP) and to drug delivery (TDD) in intervention group (PedAMINES) and control group (conventional method). Solid horizontal lines denote median and interquartile ranges; the whiskers go down to the smallest value and up to the largest; + denotes mean. Red open circles denote each individual value. Time is expressed in seconds.