Survey Results from Pharmacists Provide Support to Enhance the Organizational Response to Codes

ISMP extends our sincere appreciation to the 410 pharmacists who completed our ISMP Survey on the Pharmacists’ Role and Medication Safety During a Code this past June and July. Although most pharmacists completing our survey reported years of experience with responding to codes and various levels of training and responsibility, a surprising number of respondents felt they were ill-prepared to respond to codes. Respondents also shared numerous medication safety concerns related to code situations. Details about the survey follow.

Respondent Profile

Most survey respondents (82%) were pharmacists who currently respond to codes. Fourteen percent were pharmacists who do not respond to codes, and 4% described their pharmacy position as “Other” (e.g., pharmacy director, manager, administrator). Pharmacists reported their position as staff (63%); manager, director, or supervisor (26%); a specialized position (9%), such as a clinical pharmacist, medication safety pharmacist, or emergency department (ED) pharmacist; or an administrator/executive (2%). The patient population served by the respondents’ organizations included a combination of adult and pediatric settings (66%), adults only (29%), and pediatrics only (5%). Most pharmacists participating in our survey (60%) had more than 5 years of experience responding to codes; 12% had 4-5 years of experience; 19% had 1-3 years of experience; 4% reported less than 1 year of experience; and 5% said they have never responded to a code.

Code Participation

In 94% of respondents’ organizations, pharmacists respond to codes. Most frequently, pharmacists always attend codes when the pharmacy is open (69%), or they attend as much as possible (15%). In 10% of the respondents’ organizations, pharmacists attend codes only at certain locations or for some patient populations (e.g., ED, intensive care unit, only pediatric patients). Most often, pharmacy technicians do not accompany pharmacists to codes (79% never, 7% rarely, 6% occasionally).

Pharmacists’ Role

Most of the surveyed pharmacists who respond to codes prepare medications (98%), retrieve medications and/or equipment from code carts and other locations (94%), and advise code team leaders about medications and doses (81%). Less often, pharmacists assist with basic life support including chest compressions and/or ventilation (20%), function as a scribe (11%), defibrillate/assist with defibrillation (6%), and assist with intubation (3%). Some pharmacists reported bringing needed medications/supplies that are not in the cart, and obtaining and reviewing the patient’s medication list. Of the 10% of pharmacists who administer medications during codes, the administration routes include intravenous (100%), intraosseous (65%), endotracheal (16%), and intramuscular/subcutaneous (3%).

Code Debriefing

Seventy-five percent of respondents’ organizations debrief staff after a code. Only 9% reported that their organization always debriefs staff after a code. More often, debriefings occur sometimes (66%) or they do not occur at all (25%).

Code Training

Pharmacists who completed our survey and respond to codes told us their organization often requires them to have current basic life support (BLS) certification (72% in hospitals that serve adults and pediatrics; 75% in hospitals for adults only; 68% in pediatric-only hospitals), followed by current advanced cardiovascular life support (ACLS) certification (62% in hospitals that serve adults and pediatrics; 67% in hospitals for adults only; 16% in pediatric-only hospitals), and current pediatric advanced life support (PALS) certification (31% in hospitals that serve adults and pediatrics; 9% in hospitals for adults only; 53% in pediatric-only hospitals). More than half of pharmacists received training on the indications (56%), preparation (61%), and adult doses (58%) of medications typically used during a code. Only 44% of pharmacists who work in hospitals that serve adults and pediatrics received training about typical pediatric doses; whereas 68% of pharmacists who work in pediatric-only hospitals received training about pediatric doses. Approximately two-thirds (63%) of all responding pharmacists have been trained regarding where to find medications in the code cart, and approximately three out of four (73%) have had an opportunity to open a code cart to practice selecting and/or preparing medications. Surprisingly, only 8% of training requirements include shadowing during codes or attending mock codes and simulations, and 7% of all respondents reported no required training. Less than half (41%) of the pharmacists who responded to our survey complete annual competencies for knowledge and skills related to responding to codes. More than one-third (36%) of pharmacists do not feel that they have been adequately prepared to participate in codes.

Medication Safety Concerns

We asked respondents to list three conditions and/or medications that worry them the most when thinking about medication errors during codes. More than half of the respondents (54%) told us that making an error with a high-alert medication was their most common fear. Amiodarone, EPINEPHrine, alteplase, magnesium sulfate, and neuromuscular blocking agents were frequently listed as concerns. Approximately one-third (32%) shared concerns regarding dispensing and/or administering an incorrect medication or dose during a pediatric code. This includes making an error when calculating weight-based dosing and preparing an incorrect volume or concentration of the pediatric medication. This was more commonly reported in hospitals that serve adults and pediatrics (81%), compared to those who work in pediatric-only hospitals (8%), and in hospitals that typically only serve adults (11%). More than one out of five (23%) pharmacists worry they might compound or calculate a medication dose or infusion inaccurately, especially when commercially available infusion bags are not available and while calculating doses under pressure. One out of five respondents (20%) said that the wrong medication, dose, or rate was more likely to occur during codes due to the lack of a double check, inability to use barcode scanning, or having to administer medications without the use of an electronic health record (EHR) with clinical decision support.

Additional concerns associated with medication safety included the following:

• Due to shortages, unfamiliarity with alternative products purchased (17%) 

• Errors during a rushed, crowded, loud environment, often lacking leadership (15%)

• Lack of clear communication, including incomplete verbal orders (12%)

• Inexperience and/or lack of staff training (8%)

• Unlabeled or mislabeled syringes (6%)

• Delays in medication administration due to pharmacists’ response time, inability to locate medications in the code cart, and/or having to find medications not stocked in the code cart (5%)

• Lack of patient information (4%)

• Medication storage issues due to multiple formulations of the same medication, or picking an incorrect medication from the cart (4%)

Recommendations

Consider implementing the following recommendations to improve the code team members’ preparation and confidence when responding to codes:

Preparing for a Code

Require pharmacy participation in codes. Whenever possible, make the participation of pharmacists in codes a standard of practice within the organization when the pharmacy is open. If possible, consider sending a second pharmacist or a trained pharmacy technician to attend codes with a pharmacist to provide a double check for medications, infusions, and doses prepared by the pharmacist, or to stand by in case they are needed.

Outline responsibilities. Clearly define the roles and responsibilities for all code team members (as well as any alternates when certain code team members are unable to respond).

Maximize ready-to-use products and provide labels. When possible, provide commercially available, ready-to-use syringes and premixed medication infusions in a standard concentration(s). When choosing standard concentrations, reference the American Society of Health-System Pharmacists (ASHP) Standardize 4 Safety initiative. In the code cart, provide prepopulated label templates that specify the medication name, strength, and volume to assist in labeling practitioner-prepared medications and infusions in a standard concentration.

Provide drug information. Ensure that all pediatric code carts include emergency medication resources specific to pediatric weight ranges. Stock the most recent version of the Broselow Pediatric Emergency Tape on code carts and use it as a tool for determining the correct medication dose, based on the child’s length, especially when the patient’s weight is unknown. Consider using a well-vetted, commercially available software system or phone app; alternatively, develop organization-specific emergency medication tables that are immediately available in binders on all code carts. Each table should specify the dose and volume of code medications (by patient weight for weight-based medications and for pediatric patients) based on the organization’s standard concentration(s) (Table 1). Include pertinent information specific to each medication, such as any compounding instructions, the rate of infusion, frequency of repeat doses, and the maximum dose. For example, consider a one-page table for each weight, with 0.2 kg increments for weights less than 3 kg, 0.5 kg increments for weights between 3 kg and 10 kg, 1 kg increments for weights between 10 kg and 50 kg, and 5 kg increments for weights between 51 kg and 100 kg. Number, date, and account for each binder, and update the contents as needed. During a drug shortage or after a formulary change that requires an alternative concentration, update the concentration and corresponding dose and volume in the emergency medication tables/binder and on the prepopulated label templates. Review and approve these drug resources through the Pharmacy and Therapeutics (P&T) or code committee. If possible, incorporate the tables into your EHR.

Code reference for pediatrics. For organizations that use patient-specific tables for pediatric patients, designate a timeframe for how often a nurse should print the patient-specific table using the patient’s measured metric weight, and determine where this will be stored (e.g., secured to the pediatric patient’s bed) for reference during a code.

Separate pediatric and adult medications and supplies. Ideally, provide separate and clearly identified adult and pediatric code carts. If a universal code cart must be used, separate and identify the trays and drawers with supplies, medications, and equipment for adult versus pediatric patients.

Manage code cart medication contents. Store medications in each code cart in a standard configuration, with labels facing up and separating look-alike products. Routinely review medications ordered during codes to ensure the drugs and doses are evidence-based and readily accessible in the code cart. Remove medications not needed during a code, as access to unnecessary medications is a known source of error. Communicate with staff when a drug is removed or a new product is available in the code cart due to a drug shortage, and review the packaging, storage location, and other pertinent information.

Mandate education. Require formal training and certification for all code team members. Consider requiring BLS and ACLS certification, as well as PALS certification for key code team members (e.g., prescribers, pharmacists, nurses) working in organizations with pediatric patients. Develop organization-specific competency assessments for code team members, including pharmacists, to complete during orientation and annually. For pharmacists, include each emergency medication’s indication, calculation, and preparation of adult doses (and pediatric doses, if applicable), and the location of medications in the code cart. If feasible, consider a code team member orientation checklist and expect key team members to observe a designated number of codes, and participate in a designated number of codes with the help of a seasoned practitioner, prior to allowing the team member to independently attend the code.

Practice simulations. Require annual code simulations focusing on selecting and preparing commonly used and high-alert medications. Allow all code team members, including pharmacists, to open a mock code cart to familiarize themselves with medication packages, storage locations, and other available equipment. Confirm that code team members have access to the emergency drug binders on each code cart as well as the EHR and additional online drug information resources. Allow code team members who participate in double checking medications to practice this process and understand the expectations around the elements that must be checked (e.g., correct dose based on weight, comparison of source container to label).

During a Code

Position the code team. Identify the physician team leader during a code and establish the location of other team members so that they have a clear line of sight and can hear the directions/orders from the leader.

Gather patient information. Upon entering the room, listen to the description of the patient, noting their age, weight, diagnoses, allergies, recently administered medications, and take note of those that may still be infusing. If possible, review the patient’s medication administration record (MAR) to screen for potential adverse drug events that may have contributed to the code. Check the status of the patient’s vascular access.

Communicate doses safely. Never use drug name abbreviations during a code, or any other time. The pharmacist should repeat back each verbal order, stating the exact dose they will prepare. Pronounce each numerical digit in the dose (e.g., “sixteen, one six,” to avoid confusion with “sixty”). Ensure the prescribed medication and dose make sense in the context of the patient’s condition. Encourage staff to clarify any medication-related concerns, especially when a prescriber requests a medication not typically used during codes. Ensure the route of administration is always a part of the order and is never assumed.

Label practitioner-prepared doses. Select ready-to-use, prefilled emergency medication infusions and syringes whenever possible. Label all practitioner-prepared infusions and syringes using the prepopulated label templates supplied in the code cart.

Double check doses. When possible, have a second code team member independently double check the dose and volume with the label prior to administration. If the dose or infusion is practitioner-prepared, also share the vial so the original label and dose can be confirmed during the double check.

After a Code

Debrief staff. Shortly after a code, provide a safe learning environment for attendees to regroup and discuss what occurred during the code. Allow code team members to ask questions, share concerns, and review what went well and what could be improved. If a medication-related scenario caused difficulty for the pharmacist or another code team member, consider conducting a failure mode and effects analysis (FMEA) to determine how to better approach code-related medication processes in the future.

Secure and replenish supplies. Remove opened medications/infusions, any patient-specific emergency medication table, and any other used supplies and equipment after codes. Do not return items to the code cart that were removed during the code. Ensure a process is in place to immediately secure the remaining medications and replace/exchange the drugs and supplies that were used, including the drug information resources. Consider using radiofrequency identification (RFID) inventory systems for code cart contents and replacements. Confirm all required contents are present and ready for the next code.

Continuous Improvement

Report errors. Encourage staff to share hazardous conditions, close calls, and actual errors that have occurred during codes. Create action plans and share the steps that the organization has taken to prevent them from happening again.

Seek expertise. Reach out to colleagues, including those who attend codes at other hospitals, to share and discuss code experiences or challenging situations and how to best approach them.

^{Suggested citation:}

^{Institute for Safe Medication Practices (ISMP). Survey results from pharmacists provide support to enhance the organizational response to codes. ISMP Medication Safety Alert! Acute Care. 2022;27(20):1-5.}