Emergency Medical Services
Background: With rates as high as 1 in 6 administrations, pediatric medication dosing errors are frequent. Calculation error is among the top ten causes. We hypothesized that use of a standardized formulary with pre-calculated dosages in a large EMS system would reduce pediatric medication dosing errors. The objective of this study was to compare: 1) frequency of midazolam dosing errors during the field treatment of pediatric seizures and 2) paramedic anxiety and confidence in dosing midazolam for pediatric seizures, before and after the standardized formulary.
Methods: This was a mixed methods study of the Los Angeles County EMS system before and after implementation of a standardized formulary in February 2017. For the quantitative analysis, we utilized the EMS data registry to identify pediatric patients ≤14 years old treated with midazolam by EMS for seizure. We defined a dosing error as ±20% the weight-based midazolam dose and compared dosing errors during a one-year period before and after the formulary change. For the qualitative analysis, we surveyed paramedics to assess their level of anxiety and confidence in dosing midazolam and compared pre and post responses with the Wilcoxon signed rank test. We conducted semi-structured interviews with 20 respondents to further explore the impact on paramedic practice. Two investigators independently completed thematic coding.
Results: Of 207 patients, 10 were excluded in both groups for missing weight or dose. There were 6 dosing errors in 98 patients treated post-formulary (6.1%) compared with 15 dosing errors in 89 patients treated pre-formulary (16.9%), risk difference -10.7% (95% CI -19.8 to -1.6), p=0.02. Among 304 paramedics surveyed, anxiety decreased (p<0.001) and confidence increased (p<0.001) post-formulary. Paramedics expressed the challenges of pediatric calls, the benefits to the standardized formulary, and the ongoing challenges of pediatric medication dosing. Benefits included simplifying paramedic tasks, increasing paramedic self-efficacy, facilitating provider communication, and improving patient care.
Conclusion: Implementation of a standardized formulary reduced pediatric medication dosing errors, increased paramedic confidence in pediatric medication dosing, and facilitated prehospital care. This may improve the safety of pediatric medication administration by EMS.