Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions. Sequential and synergistic errors were observed with epinephrine delivery.

We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors.

Ventilation Circulation Assessment Circulation Management -Check for responsiveness. -Check for spontaneous respirations. (not present) -Perform head tilt/chin lift airway maneuver. -Look in mouth for oral secretions or vomitus. (not present) -Select correct size mask. ("infant/child" size) -Select correct bag size. ("infant/child" size) -Attach tubing to bag* and deliver high-flow oxygen (6-15 L/min). -Select correct size oropharyngeal airway. (50 mm) -Prepare suction device.* -Insert oropharyngeal airway. -Insert oropharyngeal airway correctly. -Use correct hand position on mask. -Perform bag-valve-mask ventilation.* -Begin ventilations within 60 seconds. -Check for chest rise with ventilations. -Auscultate lungs.* (normal) -Deliver ventilations at rate of 20-30/min. -Deliver ventilations at an appropriate tidal volume. (approx. 40-75 cc, or roughly adequate with no excessive force) -Verbalize "squeeze-release-release" and use 1:2 I-to-E ratio. -Attach cardiac monitor electrodes to chest.* -Check pulse. (absent) -Begin chest compressions.* -Begin chest compressions within 60 seconds. -Perform compressions at a rate of >100/min OR Correct EMT's slow compressions. -Correct EMT's hand position. -Call for additional, backup help. Play audio: "mother-baby not breathing." Starting rhythm: asystole. EMT informs paramedic at the start of the scenario that "the infant's extremities and trunk are cyanotic." Mother is unable to answer questions. Provide information about physical exam only if requested. Paramedic should start BVM ventilations before turning over the task to the EMT.