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

STUDY OBJECTIVE: The 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.

DESIGN: Retrospective analysis.

SETTING: All anesthetizing locations (57).

PATIENTS: All anesthesia patients at all Boston Children's Hospital anesthetizing locations from January 2008 to June 2016 were included.

INTERVENTIONS: Medication libraries, zero-tolerance philosophy, independent verification, trainee education, standardized dosing; retrospective study.

MEASUREMENTS: Number and type of medication errors.

MAIN RESULTS: 105 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).

CONCLUSIONS: Although 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.