Episode #238 Solutions to Reduce Pediatric Medication Errors during Anesthesia Care

January 22, 2025

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Our featured article is from the October 2024 APSF Newsletter. It is “Pediatric Perioperative Medication Errors” by Ying Eva Lu-Boettcher, MD and Rahul Koka, MD.

Thank you so much to Eva Lu-Boettcher and Rahul Koka for contributing to this podcast series.

We are discussing three strategies to help decrease and prevent pediatric medication errors including:

  1. Anesthesia Medication Template
  2. Pre-filled syringes
  3. Point-of-care barcode scanners

Citations:

  1. Grigg EB, Martin LD, Ross FJ, et al. Assessing the impact of the anaesthesia medication template on medication errors during anaesthesia: a prospective study. Anesth Analg. 2017;24:1617–1625. PMID: 28079581
  2. Yang Y, Rivera AJ, Fortier CR, Abernathy JH 3rd. A human factors engineering study of the medication delivery process during an anesthetic: self-filled syringes versus prefilled syringes. Anesthesiology. 2016;124:795–803. PMID: 26845139
  3. Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362:1698–1707. PMID: 20445181

APSF articles to check out related to prefilled medication syringes.

  1. Parr G, Desvarieux T, Fisher D. Medication error related to look-alike prefilled syringes. APSF Newsletter. 2019; 34:2. https://www.apsf.org/article/medication-error-related-to-look-alike-prefilled-syringes/ Accessed August 13, 2024.
  2. Hand W, Cancellaro V. “No read” error related to prefilled syringes. APSF Newsletter. 2018;33:1. https://www.apsf.org/article/no-read-errors-related-to-prefilled-syringes/ Accessed August 13, 2024.

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© 2025, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Last week, we started the conversation about pediatric medication errors during anesthesia care. Here are some facts about this threat to patient safety from Wake Up Safe, a national paediatric anesthesiology quality collaborative, that we talked last week:

  • The most common medications that result in medication errors are sedatives, hypnotics, and opioids.
  • The highest incidence of medication errors occurs during the administration phase at 65% with prescribing next at 24 % and finally preparation at 11%.
  • If we break down the administration phase, the most common type of error is wrong dose followed by syringe swap which is the accidental administration of the wrong syringe.
  • 21% of medication errors involved medication infusions.
  • And finally, the vast majority, 97% of these medication errors were deemed to be preventable.

We are continuing the conversation today, so stay tuned.

Before we dive further into the episode today, we’d like to recognize GE healthcare, a major corporate supporter of APSF. GE Healthcare has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, GE healthcare – we wouldn’t be able to do all that we do without you!”

We are returning to the October 2024 Newsletter. Our featured article is “Pediatric Perioperative Medication Errors” by Eva Lu-Boettcher and Rahul Koka. To follow along with us, head over to APSF.org and click on the Newsletter heading. The first one down is the current issue. From here, scroll down until you get to our featured article today. I will include a link in the show notes as well.

What about medication errors during pediatric anesthesia care? Are there specific interventions that may be helpful to decrease and prevent medications errors for this higher risk patient population? We are jumping back into the article now.

First up, let’s talk about the Anaesthesia Medication Template, or AMT, drug organization system. This is a formal and standardized way to organize medications in the anaesthesia workplace. This is a useful tool that has the following advantages:

  • Decreased cognitive load.
  • Makes it easier to select the correct syringe from the anaesthesia workspace.
  • Makes it easier to administer the correct drug dose.

Time to check out the literature and the 2017 article by Grigg and colleagues, “Assessing the Impact of the Anaesthesia Medication Template on Medication Errors During Anaesthesia: A Prospective Study.” I will include the citation in the show notes as well.  This was a two-phase study that looked at the AMT in simulation and in clinical practice at an academic paediatric medical centre. The first phase included direct observation of medication administration of 41 anaesthesia professionals during 2 prospective, randomized operating room simulations with and without AMT. The second phase involved 200 anaesthesia professionals who prospectively provided self-reported medication errors over a 2-year period.

And now, for the results. For the simulation phase, the odds of making a medication dosing error using the AMT were 0.21 times compared to without the AMT, and this is with controlling for scenario, session, training level, and years at training level. For the second phase when the AMT was used in clinical practice, the mean monthly error rate for all reported medication errors that reached patients decreased from 1.24 to 0.65 errors per 1000 anaesthetics. The mean monthly error rate for reported medication swap, preparation, miscalculation, and timing errors decreased from 0.97 to 0.35 per 1000 anaesthetics. There was no change in medication errors that resulted in patient harm after implementation of the AMT. The authors of this study concluded that using the AMT is an intuitive and low-cost strategy that may improve patient safety by decreasing medication errors. Are you using AMT at your institution?

Another strategy may be using prefilled syringes. The APSF and Wake Up Safe are in favour of prefilled syringes with standardized and enhanced labelling with ready-to-use medication doses to help decrease ampule/vial swap errors and decreased syringe swaps as well. If we go back into the literature, there is a 2016 qualitative research study by Yang and colleagues, “A Human Factors Engineering Study of the Medication Delivery Process during an Anesthetic: Self-filled Syringes versus Prefilled Syringes” that we need to review.

The methods included performing a work system analysis to identify system vulnerabilities. Anaesthesia professionals were directly observed during general surgery cases using only self-filled syringes and during cases when only prefilled syringes were used. A system vulnerability is an activity or event that has the potential to reduce safety, workflow efficiency, or increase drug costs and waste. This study revealed a greater number of system vulnerabilities when self-filled syringes were used compared to commercially available prefilled syringes. Some of the identified errors were due to illegible handwriting (it can be difficult to write legibly on the small syringe labels) and similar medication packaging. The authors concluded that using prefilled syringes may improve safety and efficiency during anaesthesia medication delivery, but there are still opportunities for additional improvement.

Keep in mind that there are reports of medication errors related to look-alike pre-filled syringes involving some manufacturers. It is important to select prefilled medication syringes that meet the standards set by the American Society for Testing and Materials and include labels that are easy to distinguish in clinical practice. There are two APSF articles related to the safety of prefilled syringes. We hope that you will check out the 2018 Rapid Response, “No Read” Errors Related to Prefilled Syringes and the 2019 October Newsletter article, “Medication Error Related to Look-Alike Prefilled Syringes.” I will include the link to both of these in the show notes as well.

Finally, we are going to talk about using point of care barcode scanning systems. There is evidence that this is another way to help decrease medication errors. There is a 2010 New England Journal of Medicine article by Poon and colleagues, “Effect of bar-code technology on the safety of medication administration” that we are going to talk about now. This is a before and after implementation of a barcode medication verification technology, observational study in an academic medical centre that looked at rates of errors in order transcription and medication administration. The patient population was in-patient adults.

Results included a 41% reduction in dose, route, documentation and administration errors as well as a 51% reduction in potential adverse drug events.

A more recent 2022 study in an academic children’s hospital evaluated the effects of implementing an electronic labelling system. The results of this study included a 3.6% reduction in the average daily medication discrepancy rate.

It is important to recognize that there are limitations to barcode scanning technologies that include user feasibility, compliance, cost, and availability. These newer technologies need to be used correctly and as intended for use in order to help decrease medication errors and improve patient safety. This is apparent with barcode scanning technologies that only work well if the system links with the EMR and if the barcode registers appropriately. Plus, these systems depend on close partnership with pharmacy for system updates, label changes, and medication shortage management. You can find the citations for all of the articles that we talked about in the show notes as well.

We made it to the end of the article. There is a call to action to address this threat to anaesthesia care since there is an estimated 5% medication error rate for paediatric and adult anaesthesia professionals. In addition, the harm caused by medication errors may be three times greater in paediatric patients compared to adults and the adverse evet drug rate is the highest for neonatal patients. Consideration for the use of prefilled syringes, EMR decision support, medication organization aides, and barcode scanning systems is vital to improve patient safety and decrease medication errors during anaesthesia care.

Before we wrap up for today, we are going to be hearing from the authors. I asked, ‘what do you hope to see going forward?’ Here is Lu-Boettcher now.

[Lu-Boettcher] “ I hope that data regarding both adult and pediatric anesthesia medication errors and new mitigation advancements will continue to receive our community’s attention every year. I hope that different quality and safety consortiums continue to share their improvement initiatives and make that information accessible to national and international audiences.”

[Bechtel] And now let’s take a listen to Koka’s response.

[Koka] “What would I like to see moving forward?

I would love to see more discussion and research on effective strategies for  not just prevention of errors, but also prevention of harm.

If we take the bold but necessary step of assuming that we are all human and that  we cannot fully prevent medication errors from happening,  then there has to be a natural discussion that talks about, well, if this error were to happen,  Perhaps we can do something to mitigate the harm to the patient.  And I believe that this is possible.

I believe that if you start to  break down how these errors are happening, then we can truly start to understand which mitigative and which protective barriers can be put in place to actually prevent harm from happening to patients.”

[Bechtel] Thank you so much to these APSF authors for contributing to the show today. We are looking forward to the future of pediatric anesthesia care where we can prevent medications errors before they happen no matter where you are practicing around the world. This is an important way we can help keep our patients safe.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

We hope that your 2025 is off to a great start! Listening to the podcast is a great way to learn more about anesthesia patient safety. If you get a chance, we hope that you will share this podcast and all of the APSF resources with your colleagues, team members, and anyone you know who is interested in anesthesia patient safety.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2025, The Anesthesia Patient Safety Foundation