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Hospital Pharmacy Volume 40, Number 11, pp 984­993 2005 Wolters Kluwer Health, Inc.

FEATURED ARTICLE

Standardized Vasoactive Medications: A Unified System for Every Patient, Everywhere

Kristin Niemi, PharmD,* Siobhan Geary, RN, MS, CNS, Mark Larrabee, RPh, and Kevin R. Brown, PharmD§ Abstract -- Providing medications used in emergency cardiovascular care (ECC) in an efficient and consistent manner is a cornerstone for achieving excellent patient care and safety. For neonatal, pediatric, and adult patients who move through different specialty areas in a tertiary hospital, it is essential to have a standardized protocol for these medications that can be followed regardless of location or practitioner. Our institution developed a protocol for intravenous push (IVP) and continuous infusion (CI) medications based on the Neonatal Resuscitation Program (NRP), Pediatric Advanced Life Support (PALS) and Advanced Cardiovascular Life Support (ACLS) guidelines. This protocol incorporates these guidelines into a single reference sheet (Emergency Drug Sheet) based on the patient's weight using a computer software program. The program provides the option for either pediatric (weight-based) or adult (weight-based and standard dose) dosing. The CI section uses a limited number of concentrations, which meets the JCAHO mandate. Commercially available products are used, when possible, in response to USP <797>. It also serves as the standard protocol for vasoactive medications in all patient care settings in conjunction with programmable infusion pump technology. The software program is easy to use; the Emergency Drug Sheet is easy to read; and the program is available everywhere in the hospital. The standard CI protocol used with the Emergency Drug Sheet reduces unclear orders, standardizes drug preparation, and decreases the time to medication delivery. It could serve as a model for community hospitals, as well as tertiary facilities. Key Words -- standardization; vasoactive medications; medication safety Hosp Pharm -- 2005;40:984­993

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our benchmark actions have drawn attention to the need for standardization in delivery of medications used in emergency cardiovascular care (ECC) and in critically ill patients to improve patient safety.

1. In 1999, the Institute of Medicine's report, To Err is Human, clearly outlined the need for-- and demanded action on--the standardization of many activities in health care, as a crucial step in decreasing errors.1 This

*Pediatric Pharmacist and Pharmacy Educator, Sutter Medical Center, Sacramento (SMCS); at the time of writing, Pediatric Cardiovascular Clinical Nurse Specialist, SMCS; currently, Clinical Nurse Specialist, SMCS; Senior Developer/Programmer, SMCS; §Clinical Coordinator, SMCS.

report now serves as one of the fundamental philosophies in new protocol development. 2. In the 2004 National Patient Safety Goals, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated the use of a limited number of standard concentrations for medications, which results in the elimination of the use of the "rule of six" for pediatric-continuous infusions (CI).2 3. The International Guidelines 2000 Conference on Cardiopulmonary Resuscitation (CPR) and ECC presented two significant medication changes. Amiodarone was recommended as an alternative to lidocaine for the treatment of stable ventricular tachycardia in adults, and vasopressin was recommended as an alternative to epinephrine for promoting the return of spontaneous circulation in cardiac arrest.3­5 These medications are not commercially available in premixed form, either as a bolus syringe or as a CI, so preparation requires mixing instructions, which can contribute to confusion and error during an emergency situation. The Guidelines 2000 represent the culmination of 40 years of evolution of internationally accepted evidence-based resuscitation experience.3 They serve as the basis for the medication algorithms published by the Ameri-

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Standardized Vasoactive Medications: A Unified System

can Heart Association. The missing piece is how to execute these guidelines and administer the recommended treatment in a clinically appropriate manner with minimal error. 4. In 2004, the introduction of The United States Pharmacopeia (USP) chapter <797> regulations and the resulting impact on pharmacy sterile product compounding practice forced many hospital pharmacies to examine basic workflow patterns and increased the use of commercially available preparations.6,7 In addition to the above actions, The Institute for Safe Medication Practice (ISMP) stated that due to the lack of standardization, the "rule of six" leads to medication errors.8 Kozer et al9 supported this statement with documented errors made by experienced pediatric clinicians in a setting without a standard protocol during mock resuscitations. While heated national controversy on this issue continues,10,11 a well-controlled study designed to provide evidence based information to settle the controversy is unlikely. Based on the above actions and clinical experience at Sutter Medical Center, Sacramento, (SMCS) a protocol was developed for administration of intravenous push (IVP) and CI medications based on dosing guidelines from Neonatal Resuscitation Program (NRP), Pediatric Advanced Life Support (PALS), and Advanced Cardiovascular Life Support (ACLS). The protocol was incorporated into a computer software program that was developed at SMCS. The program provides decision support and prints a patientspecific single page reference, titled Emergency Drug Sheet. An Emergency Drug Sheet is printed and

used for all patients admitted to the hospital. While a number of institutions have successfully implemented a standardized concentration protocol for a specific patient population,12 this program applies to all patients, and the procedure used is the same for all practitioners. This article describes the process used to develop the protocol, the protocol itself, the Emergency Drug Sheet, and the computer software program. The advantages of standard concentrations, including easier and more consistent physician ordering, decreased delivery time, and eliminating the need for manual calculations, are also discussed. SETTING SMCS is a 500-bed, tertiary care facility with a 55-bed, level III, Neonatal Intensive Care Unit, a 20-bed Pediatric Intensive Care Unit, and three Adult Critical Care Units. There are multiple surgical and medical specialty programs, including pediatric- and adultopen heart surgery programs, and two busy Emergency Departments. The Children's Center is a National Association of Children's Hospitals and Related Institutions (NACHRI) designated children's hospital. Infusion pumps with point of care software ("smart pumps") are used. The protocol and software program were implemented throughout the hospital in June 2004. An Emergency Drug Sheet is printed for every patient admitted to the hospital. BACKGROUND Prior to the implementation of the standard concentration protocol and use of the Emergency Drug Sheet produced by the software program, SMCS had a variety of physician ordering styles and med-

ication preparation procedures. Vasoactive drugs in the neonatal and pediatric units were ordered based on different variations of the "rule of six," and the drugs were usually prepared by the nursing staff. The Neonatal Unit and the Pediatric Unit had different and incomplete weight-based code sheets. Orders often included amount of drug, volume of diluent, and rate, but not necessarily the dose. In the neonatal and pediatric population, there were recurring issues such as inconsistent physician ordering practices, delays in drug administration due to either order clarification or preparation procedures, and mathematical calculation questions. Practice variations also existed in other areas of the hospital such as the Emergency Department and the Operating Room. The transfer of a neonatal cardiac patient between a neonatologist, a pediatric anesthesiologist, a pediatric cardiac surgeon, and a pediatric intensivist provided a specific example of the importance and complexity of this issue. The goal of the standardized protocol with a computer generated Emergency Drug Sheet was to eliminate these issues, reduce delay in delivery time, maximize the use of commercially available preparations, and meet the JCAHO goal of utilizing a limited number of standard concentrations. With this new protocol, the physician only has to order the drug, dose, and route. The diluent, drug concentration, solution volume, and infusion rate are determined by the protocol. PROTOCOL DEVELOPMENT The biggest area of resistance to the development of a hospitalwide protocol was the long-standing assumption that each clinical area is unique, and that the patients in that area could not be

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included in a central philosophy. In order to address this assumption, different physicians and nurses met in small groups with the development team to discuss the issues and review sample scenarios using various concentrations and rates. Discussion and input were welcomed. Once the possibility of a standard protocol was established, the parameters of the protocol were determined. The specific goal of the protocol was to assure that the concentration is always appropriate for the weight. The factors to be defined included: · which drugs to include · what is the minimum dose ordered (weaning parameters) · what is the minimum pump rate · what concentrations could be used for the majority of the patients · where to put weight breaks between concentrations The drug concentration is decreased when the rate for the minimum dose is no longer deliverable (see Figure 1). Certain fluid-restricted patients, or patients on extremely high doses, may require highly concentrated drips. To account for this, a separate set of maximum concentrations was established, specifically in patients when clinically indicated.13 The Maximum Concentration Emergency Drug Sheet is only used when ordered by the physician, and can only be printed in the Pharmacy -- to avoid the possibility of being printed by mistake on the Nursing Unit. This sheet contains the same elements as the other, but the maximally allowed concentrations are included. Intravenous infusion pumps are now available as "smart pumps." These pumps have drug menus entered into their software. Each drug in the menu can have

safe dosing limits attached.14,15 This technology increases patient safety by eliminating the manual math and by providing dosing alerts. However, when used with nonstandard concentrations, these benefits are not fully realized, because there are multiple pump entries required, increasing the opportunity for error. Preprogramming standard concentrations into the drug library that are consistent with the Emergency Drug Sheet allows for effective use of smart pump technology. EMERGENCY DRUG SHEET The Emergency Drug Sheet contains four sections. IV Push Medications The IVP section contains the doses for emergency IVP medications based on NRP, PALS, and ACLS guidelines. When the PALS' recommended dose for a patient's weight is equal or greater than the ACLS dose, the adult dose is displayed. Continuous Infusions Each drug in the CI section contains the normal dosing range, the mixing instructions, and a reference dose with the rate. The reference dose is either a standard or initial dose. In an emergency situation, it can be used to quickly determine the rate if the pump safety software is bypassed, or serve as a double-check reference when the smart pump is used. For weights less than or equal to 35 kg, drug entries are weight-based. When a weight of greater than 35 kg is entered, the option for either pediatric (weight-based) or adult (weight-based and standard dose) dosing guidelines is given (see Figure 2). Neonatal doses are included within the pediatric option and are indicated by age in the notes

column (see Figures 3 and 4). The adult dosing option displays only ACLS doses in the IVP section and either weight-based or standard dosing in the CI section as appropriate per drug (see Figure 5). Defibrillation/Cardioversion Doses The defibrillation doses are those recommended for biphasic defibrillators, which are used throughout the hospital. Cardioversion doses are only displayed on the pediatric sheets, as the indications for use and dosing guidelines are less variable than adults. Maintenance Fluid Rate The pediatric maintenance fluid rate16 is displayed only if the user has chosen to use pediatric dosing guidelines. SMCS COMPUTER SOFTWARE PROGRAM The software program that creates the Emergency Drug Sheet ("CodeSheetMaker") was developed by the SMCS Pharmacy Senior Programmer/Developer. Programming information includes NRP, PALS, ACLS guidelines, and the hospital's standardized concentration protocol. Tables, algorithms, and equations were prepared along with other required information for data input. The program adjusts to the specific patient instead of the clinician adjusting to multiple systems in different patient care areas. An Emergency Drug Sheet can be printed on any patient care computer by just entering a name and weight. IMPLEMENTATION The protocol was developed and implemented in 9 months. The process required close collaboration between pharmacy, nursing, and physicians. There were a num-

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Drug Alprostadil

Weight Range (kg) 0 to 5 > 5 to 15 > 15 0 to 2 >2 0 to 1.5 > 1.5 to 5 >5 0 to 1.5 > 1.5 to 5 >5 0 to 1.5 > 1.5 to 5 >5 0 to 1.5 > 1.5 0 to 10 > 10 0 to 1.5 > 1.5 0 to 3 >3 0 to 1.5 > 1.5 to 5 >5 0 to 1.5 > 1.5 to 5 >5

Standard Preparation 250 mcg/50 mL D5W 500 mcg/50 mL D5W 2,500 mcg/250 mL D5W Bolus dosing1 450 mg/270 mL D5W 20 mg/50 mL D5W 250 mg/250 mL D5W 1,000 mg/250 mL D5W 20 mg/50 mL D5W 400 mg/250 mL D5W 800 mg/250 mL D5W 0.2 mg/50 mL D5W 0.8 mg/50 mL D5W 8 mg/250 mL D5W 250 mg/50 mL D5W 2,000 mg/100 mL NS 0.2 mg/50 mL D5W 2 mg/250 mL D5W 2 g/500 mL D5W 25 mg/50 mL D5W 20 mg/100 mL D5W 2.5 mg/50 mL D5W 2.5 mg/50 mL D5W 5 mg/50 mL D5W 50 mg/250 mL D5W 2.5 mg/50 mL D5W 5 mg/50 mL D5W 50 mg/250 mL D5W 0.2 mg/50 mL D5W 0.8 mg/50 mL D5W 8 mg/250 mL D5W 0.5 mg/50 mL D5W 2 mg/50 mL D5W 20 mg/250 mL D5W 1 unit/500 mL D5W 5 units/500 mL D5W 100 units/250 mL D5W

Pre-made Concentration Reference Dose 5 mcg/mL 10 mcg/mL 10 mcg/mL Bolus dosing 1.67 mg/mL ___mL/h = 0.05 mcg/kg/min

Amiodarone*

3 mg/kg bolus every 6 h1 ___mL/h = 10 mcg/kg/minP ___mL/h = 0.5 mg/minA

Dobutamine*

Yes Yes Yes Yes

400 mcg/mL ___mL/h = 10 mcg/kg/min 1,000 mcg/mL 4,000 mcg/mL 400 mcg/mL ___mL/h = 10 mcg/kg/min 1,600 mcg/mL 3,200 mcg/mL 4 mcg/mL 16 mcg/mL 32 mcg/mL ___mL/h = 0.1 mcg/kg/minP ___mL/h = 1 mcg/minA ___mL/h = 100 mcg/kg/min ___mL/h = 0.1 mcg/kg/minP ___mL/h = 2 mcg/minA

Dopamine*

Epinephrine*

Esmolol* Isoproterenol* Lidocaine Milrinone* Nitroglycerin

Yes

5 mg/mL 20 mg/mL 4 mcg/mL 8 mcg/mL

Yes Yes

500 mcg/mL ___mL/h = 20 mcg/kg/minP 4,000 mcg/mL ___mL/h = 1 mg/minA 50 mcg/mL 200 mcg/mL 50 mcg/mL 100 mcg/mL 200 mcg/mL 50 mcg/mL 100 mcg/mL 200 mcg/mL 4 mcg/mL 16 mcg/mL 32 mcg/mL 10 mcg/mL 40 mcg/mL 80 mcg/mL ___mL/h = 0.5 mcg/kg/min ___mL/h = 1 mcg/kg/minP ___mL/h = 10 mcg/minA ___mL/h = 1 mcg/kg/min

Yes

Nitroprusside*

Norepinephrine* 0 to 1.5 > 1.5 to 5 >5 Phenylephrine* 0 to 1.5 > 1.5 to 10 > 10 Vasopressin* (milliunit/kg/h) Vasopressin* (unit/min) 0 to 10 > 10 > 35

___mL/h = 0.1 mcg/kg/minP ___mL/h = 1 mcg/minA ___mL/h = 0.1 mcg/kg/minP ___mL/h = 20 mcg/minA

2 milliunit/mL ___mL/h = 0.5 milliunit/kg/h 10 milliunit/mL 0.4 unit/mL ___mL/h = 0.04 unit/min

Pre-made solutions will be used whenever possible. All pre-made solutions are in D5W except esmolol 2,000 mg/100 mL which is in NS. Non pre-made solutions will be mixed in D5W. Vasopressin 1,000 milliunits = 1 unit 1 Taketomo CK, Hodding JH, Draus DM, eds. American Pharmaceutical Association. Pediatric Dosage Handbook. 9th ed. Hudson, OH: Lexi-Comp, Inc.; 2002. P Pediatric Dosing Guidelines for the Code Sheet Maker A Adult Dosing Guidelines for the Code Sheet Maker *Central line administration recommended. If given peripherally, consider administration with an equal volume of chaser fluid (D5W or 0.9% NaCl).

MAXIMUM HANG TIME FOR PRE-MADE SOLUTIONS IS 72 HOURS!

Figure 1. Standard vasoactive medication continuous infusion protocol used within SMCS.

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was some resistance in the Pediatric Intensive Care Unit (PICU) and Neonatal Intensive Care Unit (NICU). However, once nurses became comfortable with using the Emergency Drug Sheet, commercially Figure 2. Choice of pediatric or adult dosing guidelines available prodfor the vasoactive medication protocol program ucts, the smart used within SMCS. pump technology, and allowing the pump ber of clinicians who were resis- to calculate rates, the system was tant. It took several conversations, well accepted. The advantages and the demonstration of multiple include the following: examples (especially with the lower weight ranges), to show that Compliance with Regulatory this protocol could work. All areas Mandates of the hospital needed to be The "rule of six" is no longer addressed, including the operating used in our facility, meeting the rooms, transport services, and JCAHO NPSG 3b. In addition, the emergency rooms. Pre-planning maximal use of commercially prewas essential to successful imple- pared products assists in meeting mentation. the USP<797> requirements. An intensive, 3-week long nursing education effort was Easy to Train Staff undertaken prior to the Mitchell et al described the changeover. A specific implementa- development, implementation, and tion day timeline including and advantages of standard concentracoordinating changing out crash tions in a NICU and PICU setcarts, changing stock medications, ting.12 At the same time, the changing pharmacy systems, and authors acknowledged the difficulconverting patients was critical. ty of integrating the program with Having multiple previous discus- adult patients. Based on previous sions with various clinicians, who experience at SMCS, multiple syswould be affected by the protocol tems in different clinical areas helped make the transition result in increased education effort when training new nursing and smooth. pharmacy staff and difficulty redirecting staff from one clinical area DISCUSSION The development and imple- to another when staffing issues mentation of the protocol has been arise. Use of the Emergency Drug successful throughout the hospital, Sheet provides a single common and the staff has responded favor- system for all patients; this simpliably to the changes. Initially, there fies training and staffing.

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Easy to Use Mitchell et al used rate charts (one chart per medication), to facilitate determining the infusion rate.12 When a critically ill patient is on multiple drips, having multiple dosing charts can be cumbersome, and can lead to errors reading a chart. The Emergency Drug Sheet eliminates the need for multiple drug charts and reading lines on a chart. All the emergency medications are on one sheet, and the user enters the prescribed dose (as opposed to calculating the dose then entering the rate). If the pump software is bypassed for any reason, the rate for the reference dose can be used to begin the infusion. Faster Delivery Time The commercially available solutions are stocked in automated dispensing machines whenever possible, including the Neonatal and Pediatric Units. This allows for immediate removal when ordered, eliminating the delay for calculation, preparation, and delivery from the Pharmacy. Smoother Emergency Situation Response The Emergency Drug Sheet is printed for each patient on admission, so the information for emergency medications is already available when an emergency arises. Broselow Tape Compatibility The Broselow Tape is considered to be the gold standard for pediatric codes, when the patient's weight is unknown. Concerns about the presentation of drug doses and volumes have been documented.17 The Broselow Tape uses the "rule of six" for drip calculations. The Broselow Tape can still be used to estimate the patient weight and indicate instrumentation size, but the Emergency Drug Sheet is used for drug dosing and

Standardized Vasoactive Medications: A Unified System

Figure 3. Example of a neonatal vasoactive medication dosing Emergency Drug Sheet used within SMCS.

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Figure 4. Example of a pediatric vasoactive medication dosing Emergency Drug Sheet used within SMCS.

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Figure 5. Example of an adult vasoactive medication dosing Emergency Drug Sheet used within SMCS.

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preparation. Preprinted Emergency Drug Sheets for selected weights are kept with the Broselow Crash Cart for use when time does not permit printing. Facilitating System Change A standardized protocol makes implementing changes easier, because preprinted order sets or computerized physician order entry (CPOE) templates refer to protocol rather than specific drug concentrations. When a change is needed, no changes in paperwork or template are required. The use of commercially available products allows for easier implementation of bar code technology. Clinical Specificity Specific clinical areas can still be addressed with the protocol and the Emergency Drug Sheet. An example is the 0.5 mEq/mL sodium bicarbonate concentration, which is used in neonatal patients, as seen in Figure 3. This option appears only on lowweight patients -- based on consensus from the neonatologists and pediatric intensivists. Another example is vasopressin; there has been renewed interest in vasopressin use in critically ill patients. Limited pediatric data are available, and the appropriate indication and dose are not yet established.18,19 After discussion and review of the limited pediatric data available, as well as review of our own experience with vasopressin in pediatric patients, the pediatric intensivists selected a standard concentration delivering lower doses (on a milliunit/kg basis) than those used in the adult critical care population. These differences can be seen in Figures 4 and 5. When more information becomes available, the entries can be easily changed.

Automatic PALS to ACLS Conversion The decision of whether to use PALS or ACLS resuscitation doses for IVP medications in larger children has been an issue, because the age or weight at which the switch is made from pediatric to adult dosing varies with the drug.20 The Emergency Drug Sheet simplifies this issue. When pediatric dosing is selected, the Emergency Drug Sheet automatically limits the maximum dose at the ACLS dose at the appropriate weight for each drug. The entry "Adult dose" appears in the dose per kg column to indicate the conversion has been made. An example can be seen in Figure 4 for the naloxone high-dose entry. This line item has been programmed to convert to "Adult dose" at 20 kg. Easy PALS or ACLS Dosing Comparison When the user selects either pediatric or adult dosing guidelines, the Emergency Drug Sheet displays CI dosing units in terminology familiar to the clinician. For adolescent patients or small adults, the clinician can print both options, and then has the ability to compare both dosing options and make informed decisions.20 For example, epinephrine is commonly ordered as mcg/kg/min in the pediatric patient, but in mg/min in adults. See Figures 4 and 5 for a comparison. Innovative Design Innovative features of this system include: · automatic conversion from PALS to ACLS resuscitation doses at the appropriate weight for each drug · pediatric or adult dosing guideline option · stocking commercially available drips in automated dispensing machines for NICU and PICU patients

· centralizing all ECC information in one computer program · combining all three features: standardized concentrations, universal program for all patients, and a single page reference in one computer program · effectively eliminating manual math calculations from the medication process The challenges include: Obtaining Consensus It is sometimes difficult to obtain consensus among the various specialities during the development stage. Initial effort to include clinicians from various areas helps mitigate disagreement. Unique Clinical Requirements It can present a challenge when a rare patient, with unique clinical requirements, needs vasoactive drips. Writing and preparing patient specific orders becomes a rare event, with the inherent risks of unfamiliar processes. Due to the preparation of the protocol and subsequent implementation, this has not been a problem at SMSC. CONCLUSION The standard CI protocol used with the Emergency Drug Sheet reduces unclear orders by minimizing the information needed, standardizing drug preparation by defaulting to the protocol, and decreasing the time to delivery of medications. The protocol has enhanced physician, pharmacy, and nursing satisfaction, because there are fewer steps in drug preparation, fewer opportunities for error, less confusion, and less time utilization. This system adjusts to patient specificity, unifies hospital practice, increases staff satisfaction, promotes patient safety, and can be a model for any hospital.

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REFERENCES

1. Kohn LT, Corrigan JM, Donaldson MS, ed. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 2. Joint Commission on Accreditation of Healthcare Organization. 2004 National Patient Safety Goals. Available at: http://www.jcipatientsafety.org/show. asp?durki=9335, Accessed on April 20, 2004. 3. American Heart Association. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2000;102 (suppl 8):1158­1165. 4. Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out of-hospital cardiac arrest due to ventricular fibrillation, N Engl J Med. 1999;341:871­878. 5. Fraser GL. Important changes in the ACLS 2000 guidelines for the management of cardiac arrest, Hosp Pharm. 2002:37(5):469­473. 6. Ockerman A. Compounded sterile preparations an overview of the new standards in USP<797>. US Pharm. Available at: http://72.14.207.104/ search?q=cache:gWszz6mx0n0J:www.us pharmacist.com/index.asp%3Fshow%3 Darticle%26page%3D8_1252.htm+us+

pharm+2004+ockerman+compounded&hl=en. Accessed on August 31, 2005. 7. Kastango ES, Bradshaw BD. USP chapter 797: establishing a practice standard for compounding sterile preparations in pharmacy, Am J Health Syst Pharm. 2004; 61:1928­1938. 8. ISMP. Sstandard concentrations are safer than the rule of 6. ISMP Medication Safety Alert. 2003;8(16):2­3. 9. Kozer E, Seto W, Verjee Z, et al. Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department. BMJ. 2004; 239(7478):1321. 10.NICU-NET. Available at: http:// health.groups.yahoo.com/group/nicunet/. Accessed on March 24, 2004. 11.University of Maryland Medical Center, Rule of Six vs Standardized Drips, Available at: http://pedsccm.wustl. edu/ORG-MEET/AAP/SOCCMay04. pdf. Accessed on September 1, 2005. 12.Mitchell A, Sommo P, Mocerine T, et al. A standardized approach to pediatric parenteral medication delivery. Hosp Pharm. 2004;39:433­459. 13.Sodorff MM, et al. Recommended maximum concentrations of common acute care parenteral admixtures. Hosp

Pharm. 1999;34(8):938­942. 14.Malashock CM, et al. Effect of smart infusion pumps on medication errors related to infusion device programming. Hosp Pharm. 2004;39:460­469. 15.Wilson K, Sullivan M. Preventing medication errors with smart infusion technology. Am J Health Syst Pharm. 2004;61(2):177­183. 16.Taketomo CK, Hodding JH, Draus DM, eds. American Pharmaceutical Association. Pediatric Dosage Handbook. 9th ed. Hudson, OH: Lexi-Comp, Inc.; 2002. 17.ISMP. Broselow tape: measuring the changes from 1998 to today. ISMP Medication Safety Alert. 2004;9(4):1­2. 18.Liedel JL, Meadow W, Koogler T, et al. Use of vasopressin in refractory hypotension in children with vasodilatory shock: five cases and a review of the literature. Pediatr Crit Care Med. 2002;3(1):15­18. 19.Lechner E, Dickerson HA, Fraser CD, et al. Vasodilatory shock after surgery for aortic valve endocarditis: use of low-dose vasopressin, Pediatr Cardiol. 2004;25(5):558-561. 20.American Heart Association. Resuscitation in children: PALS or ACLS? Curr Emerg Cardio Care. 2002;13(3):5.

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