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To identify causes of prehospital pediatric errors, researchers in Michigan studied the responses of emergency medical services (EMS) personnel to a simulated pediatric emergency. Forty-five two-person EMS teams (average licensure, 7 years) used their own equipment and medications when responding to a high-fidelity programmable mannequin (SimBaby™) that simulated a 6-month-old infant with shaken baby syndrome who progressed through three clinical stages: altered mental status, seizure, and respiratory arrest. A paramedic/instructor with training in root cause analysis interviewed participants and reviewed video recordings of the sessions.
Common errors included lack of use of an oropharyngeal device with bag-valve-mask ventilation (54%), fai…