(1283) Medication Tray System for Safety During PICU Tracheal Intubations: Human Factor Considerations

Introduction: Drug administration errors are one of the most common medication errors in PICUs. The emergent nature and real-time titration of the medications required for tracheal intubations (TI) for critically ill children pose a substantial risk for drug administration errors. We implemented a Medication Tray (MT) and Administration Script in a large academic PICU (75 beds) based on our hypothesis of the feasible use of the Medication Tray and aimed to identify facilitators and barriers to implementing the system.

Methods: We developed a MT (a laminated medication template to provide standardized locations of drugs by class [anxiolysis, induction, etc.] accompanied by an administration script for providers of PICU TI. We designed a two-person system (a designated person to select the medication from the MT and a second person to administer it) with specific safety communication scripts. The proposed tray and job aid were shown to the staff for direct feedback, followed by the piloted implementations during planned TIs. Recorded data included user feedback using the System Usability Scale (SUS) and observational data from a human-factors engineer. All qualitative feedback was categorized using the Systems Engineering Initiative for Patient Safety (SEIPS 2.0) conceptual model and a PETT matrix.

Results: SUS feedback showed 7 participants (3 Physicians, 2 NPs, 2 RNs; clinical TI experience > 10 procedures) provided feedback for 6 TIs between May and July 2023. SUS scores ranged from 70 – 100 (Median = 98.8), demonstrating excellent usability. The PETT Matrix revealed several human factors improvement opportunities including intra-team communication, cognitive workload, staff training, and situation awareness. Overall, participants reported high usability and the matrix highlighted improvement considerations for future tray designs.

Conclusions: A PICU Medication Tray pilot was trialed in response to medication safety opportunities within TI procedures. The pilot utilized robust human factors tools to identify possible high feasibility and future improvement opportunities for the Medication Tray System for drug administration process safety.