• Izabela C Leahy, Meghan Lavoie, David Zurakowski, Amanda W Baier, and Robert M Brustowicz.
• Boston Children's Hospital, Department of Anesthesiology, Critical Care and Pain Medicine, 300 Longwood Ave, Boston 02115, USA; Harvard Medical School, Boston, MA, USA. Electronic address: Izabela.Leahy@ch... more ildrens.harvard.edu. less
• J Clin Anesth. 2018 Sep 1; 49: 107-111.

Study ObjectiveThe 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.DesignRetrospective analysis.SettingAll anesthetizing locations (57).PatientsAll anesthesia patients at all Boston Children's Hospital anesthetizing locations from January 2008 to June 2016 were included.InterventionsMedication libraries, zero-tolerance philosophy, independent verification, trainee education, standardized dosing; retrospective study.MeasurementsNumber and type of medication errors.Main Results105 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).ConclusionsAlthough 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.Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

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