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

Area of Science:

• Anesthesiology
• Patient Safety
• Healthcare Quality Improvement

Background:

• Anesthetic medication errors pose a significant risk to patient safety.
• Characterizing error types and implementing targeted interventions are crucial for improvement.

Purpose of the Study:

• To analyze the frequency, type, and outcomes of anesthetic medication errors over 8.5 years.
• To describe strategies used to reduce these errors.
• To evaluate the impact of a comprehensive Medication Safety Program.

Main Methods:

• Retrospective analysis of anesthesia patient data from January 2008 to June 2016.
• Involved 57 anesthetizing locations and 287,908 patient cases.
• Interventions included medication libraries, zero-tolerance policies, independent verification, trainee education, and standardized dosing.

Main Results:

• 105 medication errors were identified, with incorrect dose (55%) and incorrect medication (28%) being most common.
• The Medication Safety Program led to a 57% reduction in error incidence by 2010-2016 and a 69% reduction since 2012.
• Logistic regression showed a 13% annual reduction in the odds of medication errors.

Conclusions:

• A statistically significant reduction in anesthetic medication errors was achieved.
• Formalized Medication Safety Programs are recommended for adoption to prevent and reduce medication errors.