• C Gariel, B Cogniat, F-P Desgranges, D Chassard, and L Bouvet.
• Department of Anaesthesia and Intensive Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Bron, France.
• Br J Anaesth. 2018 Mar 1; 120 (3): 563-570.

BackgroundMedication errors are not uncommon in hospitalized patients. Paediatric patients may have increased risk for medication errors related to complexity of weight-based dosing calculations or problems with drug preparation and dilution. This study aimed to determine the incidence of medication errors in paediatric anaesthesia in a university paediatric hospital, and to identify their characteristics and potential predictive factors.MethodsThis prospective incident monitoring study was conducted between November 2015 and January 2016 in an exclusively paediatric surgical centre. Children <18 yr undergoing general anaesthesia were consecutively included. For each procedure, an incident form was completed by the attending anaesthetist on an anonymous and voluntary basis.ResultsIncident forms were completed in 1400 (73%) of the 1925 general anaesthetics performed during the study period with 37 reporting at least one medication error (2.6%). Drugs most commonly involved in medication errors were opioids and antibiotics. Incorrect dose was the most frequently reported type of error (n=27, 67.5%), with dilution error involved in 7/27 (26%) cases of incorrect dose. Duration of procedure >120 min was the only factor independently associated with medication error [adjusted odds ratio: 4 (95% confidence interval: 2-8); P=0.0001].ConclusionsMedication 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.Copyright © 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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