LEARNING IN PRACTICE

Prospective observational study on the incidence of medication errors during simulated resuscitation in a paediatric emergency department

¹ Division of Paediatric Emergency Medicine, Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8 Ontario, Canada
² Department of Pharmacy, Hospital for Sick Children, Toronto
³ Department of Clinical Biochemistry, Hospital for Sick Children, Toronto
⁴ Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto

Objectives To characterise the incidence and nature of medication errors during paediatric resuscitations.

Design A prospective observational study of simulated emergencies.

Setting Emergency department of a tertiary paediatric hospital.

Participants Teams that included a clinician who commonly leads "real" resuscitations, at least two assisting physicians, and two or three paediatric nurses.

Interventions The teams conducted eight mock resuscitations, including ordering medications. Exercises were videotaped and drugs ordered and administered during the resuscitation were recorded. Syringes and drugs prepared during the resuscitation were collected and analysed for concentrations and actual amounts.

Main outcome measures Number and type of drug errors.

Results Participants gave 125 orders for medications. In 21 (17%) of the orders the exact dose was not specified. Nine dosing errors occurred during the ordering phase. Of these errors, five were intercepted before the drug reached the patient. Four 10-fold errors were identified. In nine (16%) out of 58 syringes analysed, measured drug concentrations showed a deviation of at least 20% from the ordered dose. A large deviation (at least 50%) from the expected dose was found in four (7%) cases.

Conclusions Medication errors commonly occur during all stages of paediatric resuscitation. Many errors could be detected only by analysing syringe content, suggesting that such errors may be a major source of morbidity and mortality in resuscitated children.