Incidence, characteristics, and predictive factors for medication errors in paediatric anaesthesia: a prospective incident monitoring study

This prospective observational study was conducted with the aim of describing anaesthetic medication errors in a single paediatric centre in Lyon, France that does not perform cardiac surgery.

Anonymous and “voluntary” incident forms were provided for all patients over a three-month period. High response rates are facilitated by the presence of nurse anaesthetists involved in patient care. Nurse anaesthetists prepared all the drugs. Trainee anaesthetists were variably present. The senior anaesthetist filled out a form at the end of the procedure in PACU according to their own observations and those of the nurse anaesthetist, trainees if present, and PACU staff. Error types and mechanisms were prosectively defined. Error causes were also prospectively defined as disturbance during preparation, pressure to proceed related to emergency, fatigue, preparation and administration by two distinct professionals, lack of dilution standardisation, similar packaging, and other.

Of the 1925 general anaesthetics performed during the trial period, 1400 forms were sumitted (73%). Forty drug errors occurred involving 37 cases, a rate of any medication error per anaesthetic of 2.7%, 95% CI [0.8 – 7.3%]. Incorrect dosage (67.5%) was by far the most common error type. Incorrect pump programming (20%) and miscommunication between care providers (20%) were the most common mechanisms. Disturbance during drug preparation (25%) and non standardised drug dilution (18%) were the most common causes. Three children had transient haemodynamic changes as a result of medication errors, and no long-term effects were found (although presumably not thoroughly investigated either). In multivariate analysis, only long case duration (>120 min) was found to be statistically predictive of medication error (OR 4.5 [2.5 – 9.1] p=0.0001), although night time (midnight until 0759h) and ASA III came very close.

The authors note that this rate is higher than most adult studies and that paediatric studies generally report higher error rates, due to dilution and dose variability when compared with adults. They recognise that their results are unicentric and reflect local practice, and that the lack of external observer inevitably must lead to some underreporting.

Take home message

Medication errors in paediatric anaesthetic practice are very common, of uncertain long-term impact, and represent a serious challenge. This study is from France, where nurse anaesthetists draw up and administer medications using standard dilutions and protocols for different age groups. Error rates in countries such as Australia & New Zealand where the senior anaesthetist is both planning and executing the anaesthetic would be expected to be higher. Standardisation of pump programming and dilution would appear to be the easy fixes for a significant proportion of errors. Potential further institutional effort is infinitely possible, and it is hard to know how far to go.

Reviewed by: Dr Chris Brasher