Medication safety in pediatric anesthesia: An educational review and a call to action

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The Bottom Line

This is a comprehensive summary of an important topic that provides concrete steps for the practitioner to consider to enhance patient safety.

Type of Article

Educational review.


This educational review provides a broad review of a significant issue followed by specific recommendations for measures that can be taken to improve medication safety. There is a clear summary of the contributors to medication error in the anaesthesia context, and the review specifically addresses the contributors to a higher risk of medication error in the paediatric setting.

Suggested targets for improving safety cover a range of steps in medication administration including ordering, preparation of medications, standardisation, and delivery of infusions. There is also a section covering human factors which is valuable but less able to describe specific measures that have a strong evidence-base.

If there is one issue with some of the suggestions it is that many of the examples are likely to be more available in higher resource institutions but impractical for many settings. Solutions such as point-of-care barcode scanning, smart library infusion pumps and centralised pharmacy preparation may seem a distant shadow on the horizon for some. However, the authors are upfront about this and the underlying principles are sound. There is plenty to chew on in this read.

Reviewed by Dr Andrew Weatherall