Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis

• Published in: BMJ open 2019-11, Vol.9 (11), p.e032686-e032686
• Main Authors: Appelbaum, Nicholas, Clarke, Jonathan, Feather, Calandra, Franklin, Bryony, Sinha, Ruchi, Pratt, Phillip, Maconochie, Ian, Darzi, Ara
• Format: Article
• Language: English
• Subjects: Clinical significance; Drug administration; Emergency medical care; Human error; Medical errors; Paediatrics; Pediatrics
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2019-032686

IntroductionMedication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.ObjectivesTo describe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contribution of discrepancies in individual process steps to the occurrence of these errors.MethodsWe conducted a prospective observational study of simulated resuscitations subjected to video microanalysis, identification of medication errors, severity assessment and human reliability analysis in a large English teaching hospital. Fifteen resuscitation teams of two doctors and two nurses each conducted one of two simulated paediatric resuscitation scenarios.ResultsAt least one medication error was observed in every simulated case, and a large magnitude (>25% discrepant) or clinically significant error in 11 of 15 cases. Medication errors were observed in 29% of 180 simulated medication administrations, 40% of which considered to be moderate or severe. These errors were the result of 884 observed discrepancies at a number of steps in the drug ordering, preparation and administration stages of medication use, 8% of which made a major contribution to a resultant medication error. Most errors were introduced by discrepancies during drug preparation and administration.ConclusionsMedication errors were common with a considerable proportion likely to result in patient harm. There is an urgent need to optimise existing systems and to commission research into new approaches to increase the reliability of human interactions during administration of medication in the paediatric emergency setting.