
Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#237 Preventing Pediatric Medication Errors
Unlock the secrets of preventing pediatric perioperative medication errors with insights from our esteemed guests, Eva Lu-Boettcher and Rahul Koka. Pediatric patients face unique challenges due to variations in body weight and dosing calculations, making them particularly vulnerable to medication errors. Join us as we explore the discrepancies between self-reported and observed error rates and gain a deeper understanding of the workflow vulnerabilities anesthesia professionals encounter. We also share findings from the Wake Up Safe Collaborative, revealing the administration phase as the most error-prone and illustrating how preventative and mitigative barriers can effectively manage risks through a bowtie analysis.
Our commitment to enhancing patient safety doesn't end there. Discover the APSF Technology Education Initiatives, designed to equip anesthesia professionals with vital knowledge for safe practice. We highlight the Quantitative Neuromuscular Monitoring course, aligned with the ASA 2023 Practice Guidelines, as well as the importance of staying informed through courses on Low Flow Anesthesia and the upcoming Manual External Defibrillation, Cardioversion, and Pacing course. Our mission is to ensure that no one is harmed by anesthesia care, and this episode provides essential education and insights that every professional should incorporate into their practice.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/237-preventing-pediatric-medication-errors/
© 2025, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 3:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. Let's start with the definition of a medication error. This is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Have you been involved in a medication error event?
Speaker 3:It is likely that perioperative medication errors are not always reported are not always reported. It may be difficult to determine the actual incidence of these events, which would rely on reporting by the anesthesia professional, as well as direct observation of anesthesia professionals during medication ordering, preparation and administration. The 2016 Anesthesiology Study by Nanji and colleagues was a prospective observational study that revealed a 5.3% incidence of medication errors by direct observation, compared to the self-reported incidence of 0.004%. 0.004%. During pediatric anesthesia care, the incidence of self-reported medication errors is between 0.01 and 1.92%. Pediatric patients are at higher risk for medication errors and at higher risk for harm from these errors due to the large variations in body weight and high variability in dosing calculations. This is an area where anesthesia professionals must remain vigilant to protect patients from medication errors during anesthesia care.
Speaker 3:Before we dive further into the episode today, we'd like to recognize Prazinius Cobby, a major corporate supporter of APSF. Prazinius Cobby has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, prazinius Cobby. We wouldn't be able to do all that we do without you. We are returning to the October 2024 newsletter. Today, you may have already guessed what our featured article is. It is Pediatric Perioperative Medication Errors by Eva Lou Boettcher and Rahul Koka. To follow along with us, head over to apsforg 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, and I will include a link in the show notes as well. We are going to be hearing from both of the authors as we discuss this article. Here is one of the authors now.
Speaker 4:Hi, my name is Eva Lou Betker, a pediatric anesthesiologist at the University of Wisconsin in the United States. I am the Director of Anesthesia Quality and Safety at the Children's Hospital.
Speaker 3:I asked Lou Betcher why she wrote this article. Let's take a listen to what she had to say.
Speaker 4:Medication error is an incredibly important topic in our profession. Anesthesia professionals work under high-intensity conditions where multiple doses and classes of drugs are given during fast-paced clinical scenarios. More often than not, we are working alone to accomplish these tasks. This is a unique workflow that does not exist in other parts of the medical system. I wanted to provide evidence-based updates on where there are points of vulnerability that could potentially result in patient harm and highlight the pediatric population, who are particularly susceptible to medication errors due to large variations in body weight, resulting in high variability in dosing calculations. Importantly, there have been recent advances in medication error mitigation strategies. I wanted to bring those forward to our readers so that we as a community could stay up to date on this topic.
Speaker 3:And now it's time to hear from the next author. I will let him introduce himself and tell us why he contributed to this article.
Speaker 2:Hello, my name is Rahul Koka. I am a pediatric anesthesiologist at the Johns Hopkins Children's Center in Baltimore, maryland, where I also serve as the Surgical Director for Quality, being involved in the Wake Up Safe Collaborative. I hear of the good work that is being done at other institutions and I wanted to make sure this knowledge is disseminated.
Speaker 2:This article was one method of doing that, but we wanted to provide not just an overview of the most common causes for pediatric medication errors, but to provide some sort of representation that can help providers understand the relationships between causes and risks. We chose to show this relationship through what's called a bowtie analysis, so that providers can see what preventative and what mitigative barriers are currently being used at other hospitals and what may be missing from their own practices. I'll bet that almost every anesthesia provider either knows someone who has made a medication error or has made a medication error themselves. Now, not all these errors have necessarily led to patient harm, but drawing up and delivering a medication is one of the most repeated tasks that we perform during surgery, every single day thank you so much to these amazing authors for helping to kick off the show today, and now it's time to get into the article.
Speaker 3:Medication errors are a big threat to anesthesia patient safety. It is no wonder, since the work environment is intense, with multiple doses and classes of drugs that need to be administered at the correct time. Plus, anesthesia professionals are responsible for the entire drug administration process, from prescribing to preparation to administration, to monitoring for effects. With this great responsibility comes some significant hazards. Great responsibility come some significant hazards. Check out figure one in the article and we are going to review the different medication errors that may occur in the three phases of handling. Prescribing errors or provider knowledge gap include wrong drug, wrong dose and allergy. Preparation error in non-pre-filled syringes include labeling errors and vial swaps. Administration errors may include the following Wrong dose, syringe swap, duplicate administration, omission, overdose, wrong infusion rate, wrong time route, patient and expired medication. Just by hearing these lists you can probably guess which phase has the highest incidence of medication errors. Here are some quick data facts brought to you by Wake Up Safe, a national pediatric anesthesiology quality collaborative. The most common medications that result in medication errors are sedatives, hypnotics and opioids. The highest incidence of medication errors occur 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 involve medication infusions and, finally, the vast majority 97% of these medication errors were deemed to be preventable. The authors ask an important question how do we control the risk during medication administration? This is a great question that we need to tackle if we hope to decrease medication errors and ultimately prevent them. If we look at this phase more closely, the most critical step during medication administration is once the syringe has been pushed or the infusion started. Once the drug reaches the patient, there may be immediate and irreversible effects. This is the time when we can use technology and process-based interventions to help. Let's check out table one in the article. Here are several technology-based interventions. Number one barcode-assisted point-of-care documentation systems, which may include barcode scanning and labeling with audible and visual feedback or cues. Number two drug decision support, including EMR defaults for drug order sets, emr defaults for dosages of routinely administered medications, reminders for when the next dose is due and alerts for drug interactions with associated patient allergies or medical conditions such as renal failure. And now here are several process-based interventions A formal and consistent way of organizing medications in the anesthesia workspace Check out the Anesthesia Medication Template. Drug Organization System and we'll have more on this later.
Speaker 3:Standardization of medication trays and drawers. Pre-filled syringes to help decrease dilution errors. Preset medication infusion library. Performing documentation prior to administration, which may include barcode scanners for identification and documentation of medication in the EMR prior to administration. Connecting infusions to the most proximal IV port to avoid inadvertent boluses. Removal of high-risk medications from the electronic medication dispensing cart. Verification of drugs with another staff member prior to administration. Increase accessibility to easy and non-punitive drug error reporting and, finally, high-risk medication labeling.
Speaker 3:Which of these interventions are you using in your practice, and what about medication errors during pediatric anesthesia care? Are there specific interventions that may be helpful to decrease and prevent medication errors for this higher-risk patient population? Let's check out figure 3 for some specific evidence-based interventions. I will include this figure in the show notes as well. This analysis includes the threats that may lead to medication errors, along with preventive barriers or mitigative barriers to help prevent the wrong dose or drug being given to a patient, as well as an underdose, an overdose or an allergic reaction. For dilutional errors, interventions may include the use of pre-filled syringes and drug decision support For duplicated administration. Drug decision support can be beneficial. Mislabeling of drug syringes may be prevented by standardized dilutions and barcode-assisted point-of-care. Vial swaps may be prevented by barcode-assisted point-of-care and using the anesthesia medication template Infusion pump. Misprogramming interventions may include double-person check for high-risk medications and preset medication templates. Mitigative barriers to help prevent medication errors include using standard dilutions that are readily available, as well as the removal of high-risk medications.
Speaker 3:We have more to talk about when it comes to pediatric perioperative medication errors and we are going to hear from the authors again, so we hope that you will tune in next week. Spoiler alert we will be talking about the anesthesia medication template drug organization system, pre-filled syringes and point-of-care barcode scanners. If you have any questions or comments from today's show, please email us at podcast at apsforg. 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 APSForg for detailed information and check out the show notes for links to all the topics we discussed today.
Speaker 3:We are going to be talking about the newest APSF Technology Education Initiative on an upcoming episode. But before we do, you have time to complete the Quantitative Neuromuscular Monitoring course. This course consists of six topics designed to empower the anesthesia professional with the knowledge required to safely and effectively use quantitative neuromuscular monitoring. This is aligned with the ASA 2023 Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade. I will include a link to the course in the show notes. We hope that you will also check out the Low Flow Anesthesia course and stay tuned for the new course on Manual External Defibrillation, cardioversion and Pacing that will be released soon. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.