• 
• 

Three Part Question

Are [Paramedics'][able to perform drug calculations] with [100% accuracy]

Clinical Scenario

Paramedics may be exposed to incidents in uncontrolled environments, managing potentially critically ill patients, other people, and other emergency services. In the presence of these factors, can paramedics still conduct drug calculations with a high degree of accuracy?

Search Strategy

Medline: 1950 to end of November 2007, CINHAL: 1982 to end of November 2007, EMBASE: 1980 to end of November 2007.

Medline:(emergency medical service$.sh OR emergency medical technic$.sh OR ambulance$.sh OR air ambulance$.sh OR military medicine.sh OR emergency treatment.sh OR emergency medicine.sh OR first aid.sh) AND (pre-hospital.ti OR pre-hospital.tw OR prehospital.ti OR out of hospital.tw OR out-of-hospital.tw OR (ambulance$ or air ambulance$).tw OR paramedic$.ti,tw) AND (drug calculation.tw OR medication calculation.tw OR maths.tw OR mathematics.tw OR students.tw OR nursing.tw OR maths skills.tw OR medication safety.tw OR drug administration errors.tw OR nurse education.tw OR numeracy skills.tw OR student nurses.tw OR dosage calculations.tw OR medication administration.tw OR pharmacological skills.tw OR problem solving.tw OR problem-solving.tw OR calculation.tw OR medication-related errors.tw OR medication calculation skills.tw OR calculation methods.tw OR mathematical skills.tw OR drug calculation skills.tw OR conceptualizing drug calculations.tw OR drug dosages.tw OR mathematical anxiety.tw OR math anxiety.tw OR mathematical comprehension.tw) LIMIT to (Humans AND English)

CINHAL:(emergency medical service$.sh OR emergency medical technic$.sh OR ambulance$.sh OR military medicine.sh OR emergency medicine.sh OR emergency care.sh OR emergency patients.sh OR prehospital care.sh OR transportation of patients.sh OR first aid.sh OR mass casuality incident.sh) AND (pre-hospital.ti OR pre-hospital.tw OR prehospital.ti OR out of hospital.tw OR out-of-hospital.tw OR (ambulance$ or air ambulance$).tw OR paramedic$.ti,tw) AND (drug calculation.tw OR medication calculation.tw OR maths.tw OR mathematics.tw OR students.tw OR nursing.tw OR maths skills.tw OR medication safety.tw OR drug administration errors.tw OR nurse education.tw OR numeracy skills.tw OR student nurses.tw OR dosage calculations.tw OR medication administration.tw OR pharmacological skills.tw OR problem solving.tw OR problem-solving.tw OR calculation.tw OR medication-related errors.tw OR medication calculation skills.tw OR calculation methods.tw OR mathematical skills.tw OR drug calculation skills.tw OR conceptualizing drug calculations.tw OR drug dosages.tw OR mathematical anxiety.tw OR math anxiety.tw OR mathematical comprehension.tw) LIMIT to (Humans AND English)

EMBASE:(ambulance*:de OR 'prehospital care':de OR 'emergency health service':de OR 'paramedical personnel':de OR 'military medicine':de OR 'first aid':de OR 'emergency medicine':de OR 'emergency treatment':de OR 'air ambulance':de OR prehospital:de OR paramedic*:ab,ti OR ambulance*:ab,ti OR 'out-of-hospital':ab,ti OR 'out of hospital':ab,ti OR ems:ab,ti OR emt:ab,ti OR 'emergency services':ab,ti OR 'emergency medical services':ab,ti OR 'emergency technicians':ab,ti OR 'emergency practitioner':ab,ti OR 'emergency dispatch':ab,ti OR 'emergency despatch':ab,ti OR 'first responder':ab,ti OR 'emergency rescue':ab,ti OR 'emergency resus':ab,ti AND ('drug calculation':ab,ti OR 'medication calculation':ab,ti OR maths:ab,ti OR mathematics:ab,ti OR students:ab,ti OR nursing:ab,ti OR 'maths skills':ab,ti OR 'medication safety':ab,ti OR 'drug administration errors':ab,ti OR 'nurse education':ab,ti OR 'numeracy skills':ab,ti OR 'student nurses':ab,ti OR 'dosage calculations':ab,ti OR 'medication administration':ab,ti OR 'pharmacological skills':ab,ti OR 'problem solving':ab,ti OR 'problem-solving':ab,ti OR calculation:ab,ti OR 'medication-related errors':ab,ti OR 'medication calculation skills':ab,ti OR 'calculation methods':ab,ti OR 'mathematical skills':ab,ti OR 'drug calculation skills':ab,ti OR 'conceptualizing drug calculations':ab,ti OR 'drug dosages':ab,ti OR 'mathematical anxiety':ab,ti OR 'math anxiety':ab,ti OR 'mathematical comprehension':ab,ti) LIMIT to (Humans AND English).

Search Outcome

A total of 1,266 articles were located in the three databases, of which two were suitable for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hubble et al, 2000, U.S.A.	109 Qualified Paramedics from North Carolina, U.S.A.	Descriptive	Drug calculation accuracy on a 10-item questionnaire	Mean test score was 51.4%	Small numbers, sample taken from North Carolina only. Paramedics reported that they infrequently used calculations in practice.
LeBlanc et al, 2005, Canada	30 qualified flight paramedics of varying qualification levels from Canada	Descriptive	Drug calculation accuracy in high (post-simulated) patient and low-stress (classroom) situations,	43.1% Correct in high stress situations, 57.9% in low stress situations	Small numbers, high-stress drug calculations were conducted after the stressor had been applied (not during. Single service sample.

Comment(s)

These findings are supported in the nursing (see Faddis, Harne-Britner et al and Santamaria et al) and medical (see Kozer et al) literature and confirm that a majority of healthcare providers are not able to calculate drug dosages accurately.

Clinical Bottom Line

Even when paramedics are not under on-the-job pressure their ability to accurately perform drug calculations is poor.

References

1. Hubble MW, Paschal KR, Sanders TA. Medication calculation skills of practicing paramedics Prehosp Emerg Care 2000;4(3):253-60
2. LeBlanc VR, MacDonald RD, McArthur B, King K, Lepine T Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator Prehosp Emerg Care 2005;9(4):439-44.
3. Faddis MO. Eliminating errors in medication. Am J Nurs 1939;39:1217–23.
4. Harne-Britner S, Kreamer CL, Frownfelter P, et al. Improving medication calculation skills of practicing nurses and senior nursing students: a pilot study. J Nurses Staff Dev 2006;22:190–5.
5. Santamaria N, Norris H, Clayton L, et al. Drug calculation competencies of graduate nurses. Collegian 1997;4:18–21.
6. 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;329:1321.