Medication errors in a pediatric anesthesia setting: Incidence, etiologies, and error reduction strategies

Abstract

Study objectiveThe objective of the study was to: a) characterize the frequency, type, and outcome of anesthetic medication errors spanning an 8.5-year period, b) describe the targeted error reduction strategies and c) measure the effects, if any, of a focused, continuous, multifaceted Medication Safety Program. DesignRetrospective analysis. SettingAll anesthetizing locations (57). PatientsAll anesthesia patients at all Boston Children's Hospital anesthetizing locations from January 2008 to June 2016 were included. InterventionsMedication libraries, zero-tolerance philosophy, independent verification, trainee education, standardized dosing; retrospective study. MeasurementsNumber and type of medication errors. Main results105 medication errors were identified among the 287,908 cases evaluated during the study period. Incorrect dose (55%) and incorrect medication (28%) were the most frequently observed errors. Beginning within 3 years of the implementation of the 2009 Medication Safety Program, the incidence declined to an average of 3.0 per 10,000 cases in the years from 2010 to 2016 (57% reduction) and declined to an average of only 2.2 per 10,000 cases since 2012 (69% reduction). Logistic regression indicated a 13% reduction per year in the odds of a medication error over the time period (odds ratio = 0.87, 95% CI: 0.79–0.95, P = 0.004). ConclusionsAlthough medication errors persisted, there was a statistically significant reduction in errors during the study period. Formalized Medication Safety Programs should be adopted by other departments and institutions; these Programs could help prevent medication errors and decrease their overall incidence.