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

Gariel, Claire; Cogniat, Bérengère; Desgranges, François-Pierrick; Chassard, D.; Bouvet, Lionel

doi:10.1016/j.bja.2017.12.014

Cited by 49 publications

(66 citation statements)

References 37 publications

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“…Consistent with previous literature, multiple studies included in this review reported increased rate of medication error, critical incident, and/or cardiac arrest in patients <1 year of age . Several included studies found no association between age and risk of medication error or critical incident rate . Of note, the studies that did not find an association between age and risk had among the smallest sample sizes of those included in this review.…”

Section: Discussionsupporting

confidence: 77%

“…It is noteworthy that there is considerable heterogeneity with regard to the country in which the study took place, including European, North American, African, and Asian nations. Time period of patient observation is also an important source of heterogeneity among included studies.…”

Section: Discussionmentioning

confidence: 99%

“…Time period of patient observation is also an important source of heterogeneity among included studies. Study periods range from 3 months to 15 years …”

Section: Discussionmentioning

confidence: 99%

“…The criteria for what events constitute medication error have been subject to debate and variation in the literature . The multiplicity of terms used to refer to the same concepts further complicates this issue, for example, the frequent interchangeable use of “medication error” and “drug error.” Variations in the definition of medication error have likely led to the observed variation in frequency of medication errors in the pediatric setting . Accordingly, the studies included in this systematic review employ varying definitions of medication error, as shown in Table S1.…”

Section: Discussionmentioning

confidence: 99%

“…Pediatric patients may be more susceptible to medication error compared with adult patients . Investigations of medication error in pediatric anesthesia have ranged dramatically from 0.01% to 1.92% of anesthetic uses . Challenges to assessing medication error in pediatrics more broadly include variation in definition, research setting, and methodology .…”

Section: Introductionmentioning

confidence: 99%

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Frequency of medication error in pediatric anesthesia: A systematic review and meta‐analytic estimate

Feinstein

Pannunzio

Castro

2018

Pediatric Anesthesia

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Summary Background Clinical evidence shows that pediatric anesthesia patients are subject to a higher rate of life‐threatening medical errors than their adult counterparts. Medication error in adult anesthesia is estimated to occur to 1 in 133 anesthetic administrations, but such a figure has not been determined for pediatric anesthesia patients. Individual studies of medication error in pediatric anesthesia have ranged from rates of 0.01% to 1.92% of anesthetic uses. The present study is a systematic review that employs a meta‐analytic estimate to determine the rate of medication error in pediatric anesthesia. Methods A systematic review of the literature on pediatric anesthesia medication error was conducted using Medline, Cochrane Database, PROSPERO, and Clinicaltrials.gov. A meta‐analytic estimate was used to determine the medication error rate for all of the included studies. Subgroup sensitivity analysis was used to evaluate possible sources of heterogeneity in included studies. Results Of the 433 initially screened records, 13 studies met inclusion criteria. Meta‐analytic estimate of medication error rate across all studies was 0.08% (95% CI 0.05%‐0.10%), or 1 out of 1250 anesthetics. Ten different countries were represented in the studies. Sample size of anesthetics reported on ranged from 296 to 2 316 635. Data collecting periods ranged from 3 months to 15 years. Six included studies individually reported higher rates of medication error in patients under 1 year of age. Conclusion The present systematic review revealed a medication error rate of 1 per 1250 anesthetic administrations in pediatric anesthesia. This result is significantly lower than would be expected given reported rates of medication error in adult anesthesia, which raises questions regarding the validity of research methods and reporting of medication error in pediatric anesthesia. Future investigations of medication error should employ methodologies other than self‐reporting of error, such as retrospective chart review.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

“…Time period of patient observation is also an important source of heterogeneity among included studies. Study periods range from 3 months to 15 years …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Frequency of medication error in pediatric anesthesia: A systematic review and meta‐analytic estimate

Feinstein

Pannunzio

Castro

2018

Pediatric Anesthesia

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Catecholamine‐induced acute myocardial stunning after accidental intra‐operative noradrenaline bolus

Rémond

Leporati

Proeschel

et al. 2022

Anaesthesia Reports

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We report a case of catecholamine-induced acute myocardial stunning that occurred in a six-year-old girl. This was triggered by an accidental noradrenaline injection during general anaesthesia for dental surgery. The clinical course was favourable, although cardiac enzymes and echocardiography were significantly altered. The child was discharged home on the second postoperative day, after complete clinical resolution. We emphasise the need to consider shortening the surgical procedure, and to closely monitor patients following a medication error involving vasopressors even in the absence of symptoms. We highlight the importance of a controlled process for storing, identifying, preparing, and handling medications. The identification of weaknesses in the overall process of drug prescription and administration is of utmost importance.

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Back to Basics: Medication Safety

Spruce¹

2019

AORN Journal

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Perioperative nurses administer some medications but are primarily responsible for obtaining, preparing, and documenting medications. Unlike personnel in many other patient care areas, perioperative personnel may not have immediate access to a pharmacist; this lack of pharmacy support can complicate medication administration processes. A variety of medication errors occur in the perioperative setting and can negatively affect patients and personnel. Perioperative nurses should review regulatory information and professional organization guidance documents when they work with other health care team members to address medication safety issues. Some recommendations include submitting clear medication orders, using aseptic technique when transferring medications to the sterile field, and using standardized labeling. In addition, perioperative nurses should obtain only one patient's medications from a dispensing unit at a time and prepare one medication at a time. After reviewing this article and the supporting literature, perioperative nurses should have increased knowledge about medication safety.

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

Abstract: Medication errors are not uncommon in paediatric anaesthesia. Identification of the mechanisms related to medication errors might allow preventive measures that can be assessed in further studies.

Cited by 49 publications

References 37 publications

Frequency of medication error in pediatric anesthesia: A systematic review and meta‐analytic estimate

Frequency of medication error in pediatric anesthesia: A systematic review and meta‐analytic estimate

Catecholamine‐induced acute myocardial stunning after accidental intra‐operative noradrenaline bolus

Back to Basics: Medication Safety

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