Anesthesia Patient Safety Podcast

#238 Solutions to Reduce Pediatric Medication Errors during Anesthesia Care

• Anesthesia Patient Safety Foundation • Episode 238

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Can we significantly reduce pediatric medication errors in anesthesia care? This podcast episode explores the urgent need to address medication errors in pediatric anesthesia, highlighting effective strategies to improve patient safety. We discuss the implementation of tools such as the Anesthesia Medication Template, pre-filled syringes, and barcode scanning systems, as well as insights from experts on enhancing current practices.

• Examination of medication error statistics in pediatric anesthesia
• Discussion of the Anesthesia Medication Template (AMT) and its benefits
• Overview of pre-filled syringes as a safety measure
• Insights on challenges with pre-filled syringes
• Evaluation of barcode scanning systems and their impact on safety
• Expert opinions on future trends in medication safety
• Emphasis on proactive strategies to prevent medication errors

For healthcare professionals focused on refining patient safety, this episode is packed with practical insights and data-driven recommendations that could revolutionize your approach to pediatric care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/238-solutions-to-reduce-pediatric-medication-errors-during-anesthesia-care/

© 2025, The Anesthesia Patient Safety Foundation

Speaker 1:

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. Last week, we started the conversation about pediatric medication errors during anesthesia care. Here are some quick facts about this threat to patient safety from Wake Up Safe, a national pediatric anesthesiology quality collaborative that we talked about 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 involve medication infusions. Errors involve 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 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 wouldn't be able to do all that we do without you.

Speaker 3:

We are returning to the October 2024 newsletter. Our featured article again today 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. Along with us, head over to APSForg and click on the newsletter heading. The first one down is the current issue and 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 medication errors for this higher risk patient population? We're jumping back into the article now.

Speaker 3:

First, let's talk about the Anesthesia Medication Template, or AMT Drug Organization System. This is a formal and standardized way to organize medications in the anesthesia workplace. This is a useful tool that has the following advantages Decreased cognitive load. Makes it easier to select the correct syringe from the anesthesia workspace and makes it easier to administer the correct drug dose. Time to check out the literature and the 2017 article by Gregg and colleagues Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia a Prospective Study. I will include the citation in the show notes as well.

Speaker 3:

This was a two-phase study that looked at the AMT in simulation and in clinical practice at an academic pediatric medical center. The first phase included direct observation of medication administration of 41 anesthesia professionals during two prospective randomized operating room simulations, with and without AMT. The second phase involved 200 anesthesia professionals who prospectively provided self-reported medication errors over a two-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 force, 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 1,000 anesthetics. The mean monthly error rate for reported medication swap, preparation, miscalculation and timing errors decreased from 0.97 to 0.35 per 1,000 anesthetics. 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.

Speaker 3:

Are you using AMT at your institution? Another strategy may be using pre-filled syringes. The APSF and Wake Up Safe are in favor of pre-filled syringes with standardized and enhanced labeling with ready-to-use medication doses to help decrease ampule and vial swap errors and decrease syringe swaps as well 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 pre-filled syringes that we need to review versus pre-filled syringes. That we need to review.

Speaker 3:

The methods included performing a work system analysis to identify system vulnerabilities. Anesthesia professionals were directly observed during general surgery cases using only self-filled syringes and during cases when only pre-filled 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 pre-filled 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 pre-filled syringes may improve safety and efficiency during anesthesia medication delivery, but there are still opportunities for additional improvement.

Speaker 3:

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 pre-filled 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 pre-filled syringes. We hope that you will check out the 2018 Rapid Response no Read Errors Related to Pre-Filled Syringes and the 2019 October newsletter article Medication Error Related to Lookalike Pre-Filled Syringes. I will include the link to both of these in the show notes as well.

Speaker 3:

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 Barcode 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 center that looked at rates of errors in order, transcription and medication administration. Looked at rates of errors in order, transcription and medication administration. The patient population was in inpatient 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 labeling system. The results of this study included a 3.6% reduction in the average daily medication discrepancy rate.

Speaker 3:

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. 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 partnerships 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.

Speaker 3:

We made it to the end of the article. There is a call to action to address this threat to anesthesia care, since there is an estimated 5% medication error rate for pediatric and adult anesthesia professionals. In addition, the harm caused by medication errors may be three times greater in pediatric patients compared to adults, and the adverse event drug rate is the highest for neonatal patients. Considerations for the use of pre-filled syringes, emr decision support, medication organization aids and barcode scanning systems is vital to improve patient safety and decrease medication errors during anesthesia 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 Lou Boettcher now.

Speaker 4:

I hope that data regarding both adult and pediatric anesthesia, medication errors and new medication 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.

Speaker 3:

And now let's take a listen to Koka's response.

Speaker 2:

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

Speaker 3:

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 medication errors before they happen, no matter where you're practicing in the world. This is an important way that we can work to help keep our patients safe. 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. 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.