Paeds Vivas · professional-practice-and-evidence
Medication safety and error prevention in children — branching viva
Viva on the medication-use process, paediatric vulnerability, tenfold dosing errors, the Swiss-cheese mechanism, and the layered prevention and response system.
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Study tools
Target exams
RACP DCEMRCPCH ClinicalRCPSC Pediatrics
Prompt
Ward: a six-month-old infant becomes apnoeic shortly after a weight-based opioid infusion is started; the nurse has stopped the pump and the baby is dusky with a pulse; the order was written for a correct dose but the pump was programmed ten times too fast; a registrar who wrote the order is present and distressed.
Opening (candidate)
My first priority is the child. I would support the airway and breathing, give naloxone for the suspected opioid effect, and call for senior and PICU help. I would keep the pump stopped and preserve its settings, the syringe and the original order, and I would check whether any other child is on the same protocol. Once the child is safe I would escalate to the consultant, report the incident, and speak with the family honestly. [1] [13]
References5ShowHide
- [1]Kaushal R Medication errors and adverse drug events in pediatric inpatients. JAMA, 2001.PMID 11311101
- [4]Stucky ER Prevention of medication errors in the pediatric inpatient setting. Pediatrics, 2003.PMID 12897304
- [8]Kozer E The effect of detection approaches on the reported incidence of tenfold errors. Drug safety, 2006.PMID 16454544
- [13]Reason J Human error: models and management. The Western journal of medicine, 2000.PMID 10854390
- [14]Konwinski L Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach. Journal of patient safety, 2024.PMID 38231892