ABSTRACT
The purpose of this article is to study the effect of the introduction of a color-coded tool on medication administration in a simulated pediatric resuscitation. A prospective, randomized controlled trial was conducted at 4 geographically distinct U.S. hospitals of a corporate healthcare system including one urban children's hospital and 3 community hospitals. Emergency nurses participated in 2 videotaped simulated pediatric stabilization events. Performance was evaluated for (1) methods used to calculate/convert medication dose, (2) selection of correct medications, (3) proper preparation of the medication, and (4) measurement of medication doses. Nurses at implementation sites had access to a new color-coded print tool. Fifty-three registered nurses pre- and 32 postimplementation were each given 5 pediatric emergency medication orders. Most common errors observed were incorrect reconstitution, wrong medication chosen, and medication amounts measured not consistent with the stated dose. This study identifies areas in need of improvement in the pediatric medication process including the need for improved processes for standardized medication ordering and safe drug packaging, attention to human factors design of a tool, and improved education regarding use of the tool.