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• W2783719266 abstract "In this issue of the British Journal of Anaesthesia, Burton and colleagues1Burton Z. Woodman N. Harvlerode Z. Engelhardt T. Medication errors in paediatric anaesthesia—a cultural change is urgently needed.Br J Anaesth. 2018; 120: 601-603Abstract Full Text Full Text PDF PubMed Google Scholar present a survey on medication errors amongst paediatric anaesthetists attending a scientific meeting in the UK. Whilst 60% of respondents experienced paediatric drug errors at least once a year, only 15% reported higher error rates of at least once a month. The authors suspect that these results probably underestimate true frequencies. They support this statement mainly with data published by Nanji and colleagues,2Nanji K.C. Patel A. Shaikh S. Seger D.L. Bates D.W. Evaluation of perioperative medication errors and adverse drug events.Anesthesiology. 2016; 124: 25-34Crossref PubMed Scopus (158) Google Scholar who detected medication errors in adult anaesthesia as often as once per 20 drug administrations or once in every second anaesthesia patient. One-third of errors resulted in an observable patient harm. Another trial also using direct observation for data collection found an even higher rate of about one error per 10 drug administrations, but errors documenting drug administration in the anaesthesia record were also included.3Merry A.F. Webster C.S. Hannam J. et al.Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.Br Med J. 2011; 343: d5543Crossref PubMed Scopus (134) Google Scholar A prospective incident monitoring study, published in this issue of the BJA, found an incidence of one error per 38 anaesthetics in a university paediatric hospital.4Bouvet L. Gariel C. Cogniat B. Desgranges F.P. Chassard D. Incidence, characteristics, and predictive factors of medication errors in paediatric anaesthesia. A prospective incident monitoring study.Br J Anaesth. 2018; 120: 563-570Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Considering questionable definitions of errors and harm in such studies,5Bowdle T.A. Jelacic S. Nair B. Evaluation of perioperative medication errors.Anesthesiology. 2016; 125: 429-431Crossref PubMed Scopus (7) Google Scholar the true incidence of errors may still be unclear, and there is a relevant gap between the actual error rate and self-perceived incidences (e.g. one per 133 anaesthesia patients).6Webster C.S. Merry A.F. Larsson L. McGrath K.A. Weller J. The frequency and nature of drug administration error during anaesthesia.Anaesth Intensive Care. 2001; 29: 494-500Crossref PubMed Google Scholar An example of the potential extent of this gap is provided by an observational study conducted in a paediatric emergency department, in which a drug dosing error was defined as a 10-fold deviation from the correct dose. During the study period, the self-reported incidence of medication errors was one in 22 500 drug administrations. An audit of the patients' charts, however, revealed that one in 766 medication orders actually contained a 10-fold dosage error.7Kozer E. Scolnik D. Keays T. Shi K. Luk T. Koren G. Large errors in the dosing of medications for children.N Engl J Med. 2002; 346: 1175-1176Crossref PubMed Scopus (59) Google Scholar Hence, the rate of documented dosage errors was 30-times higher than the self-reported incidence of medication mistakes. The actual rate of medication errors, however, is likely to be even higher, as the processes of drug preparation and administration have a high potential for additional errors to occur, regardless of correctly written medication orders. The APRICOT-trial is another example for the questionable validity of study designs relying solely on self-reporting. Although this trial targeted complications in paediatric anaesthesia in general and was not focussing on medication errors, the reported incidence of one drug error per 635 paediatric anaesthesia patients (49 in 31 127 patients) is unlikely,8Habre W. Disma N. Virag K. et al.Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe.Lancet Respir Med. 2017; 5: 412-425Abstract Full Text Full Text PDF PubMed Scopus (368) Google Scholar as it is far below error rates described in adult anaesthesia practice.6Webster C.S. Merry A.F. Larsson L. McGrath K.A. Weller J. The frequency and nature of drug administration error during anaesthesia.Anaesth Intensive Care. 2001; 29: 494-500Crossref PubMed Google Scholar, 9Llewellyn R.L. Gordon P.C. Wheatcroft D. et al.Drug administration errors: a prospective survey from three South African teaching hospitals.Anaesth Intensive Care. 2009; 37: 93-98Crossref PubMed Google Scholar, 10Cooper L. Nossaman B. Medication errors in anesthesia: a review.Int Anesthesiol Clin. 2013; 51: 1-12Crossref PubMed Scopus (26) Google Scholar There is evidence to suggest that drug errors occur more frequently in children than in adults, regardless of the care setting (ward, intensive care unit or emergency department), considering the need for individual dose calculations, the lack of familiarity with dose ranges and the susceptibility for inaccurately prepared drug solutions.11Kaufmann J. Wolf A.R. Becke K. Laschat M. Wappler F. Engelhardt T. Drug safety in paediatric anaesthesia.Br J Anaesth. 2017; 118: 670-679Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 12Kaufmann J. Laschat M. Wappler F. Medication errors in pediatric emergencies: a systematic analysis.Dtsch Arztebl Int. 2012; 109: 609-616PubMed Google Scholar For example, in one paediatric hospital, the observed rate of potentially dangerous prescribing errors was three times higher13Kaushal R. Bates D.W. Landrigan C. et al.Medication errors and adverse drug events in pediatric inpatients.JAMA. 2001; 285: 2114-2120Crossref PubMed Scopus (1403) Google Scholar than the rate observed in an identically designed study in adults.14Bates D.W. Leape L.L. Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults.J Gen Intern Med. 1993; 8: 289-294Crossref PubMed Scopus (317) Google Scholar Summarizing, surveys or trials relying solely on self-reporting for detection of errors are unreliable, as unrecognized errors cannot be reported systematically, and an uncertain proportion of recognized errors will not be reported as a result of intentional or unintentional omission of the reporter. While large efforts (e.g. an external observer) would be necessary to detect unrecognized errors, a recognized yet unreported mistake means simply losing a precious opportunity to improve patient safety. An incident or error reporting system is the most frequent demanded measure when articles on medications safety were analysed.15Wahr J.A. Abernathy 3rd, J.H. Lazarra E.H. et al.Medication safety in the operating room: literature and expert-based recommendations.Br J Anaesth. 2017; 118: 32-43Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Error reporting enhances team vigilance for certain incidents and can help identify typical pitfalls, individual deficiencies of knowledge or organizational weaknesses. Hiding a mistake is destructive for the culture of safety. An important feature of the survey of Burton and colleagues1Burton Z. Woodman N. Harvlerode Z. Engelhardt T. Medication errors in paediatric anaesthesia—a cultural change is urgently needed.Br J Anaesth. 2018; 120: 601-603Abstract Full Text Full Text PDF PubMed Google Scholar was the evaluation of the participants' reporting attitudes. It demonstrated that 36% of respondents would only report errors resulting in actual patient harm. Although the reasons for that attitude remain unclear, most participants regarded a ‘no blame’ drug error reporting and review system as a strategy to reduce errors. An appropriate institutional error culture is essential to improve patient safety, yet it would be wrong and too easy to relieve all individuals from their own responsibility. Some medical providers are more enthusiastic about safety issues than others, and acceptance of personal susceptibility for errors also differs. Categorical denial of susceptibility to errors, which is common even in senior medical leaders, precludes all measures to prevent them, and is a rejection of fundamental principles to improve patient safety as outlined in the publication ‘To err is human’.16Kohn L.T. Corrigan J.M. Donaldson M.S. To Err is human: building a safer health system. National Academy Press, Washington, DC1999Google Scholar Seniority may contribute to overestimation of one's own capabilities and leads to reduced awareness of individual fallibility.17Roeder N. Wächter C. Bedeutung von Humanfaktoren im Qualitäts- und Risikomanagement in Medizin und Luftfahrt.Das Krankenhaus. 2015; 107: 126-136Google Scholar The statement ‘Where I am, there is quality’ illustrates the perception that experience and hierarchy trumps existing safety structures. This attitude is highlighted in a survey of more than 1000 health care professionals, demonstrating lower acceptance of personal susceptibility for errors in senior staff.18Sexton J.B. Thomas E.J. Helmreich R.L. Error, stress, and teamwork in medicine and aviation: cross sectional surveys.Br Med J. 2000; 320: 745-749Crossref PubMed Scopus (4) Google Scholar Abundant evidence shows that there is no infallibility amongst experienced clinicians. On the contrary, their personal fallibility (such as the fallibility of any human) endangers patients. For instance, when anaesthetists were asked to calculate the correct amount of a catecholamine needed for a predefined infusion rate, only 15% of participants were able to answer correctly. Errors ranged between 1/50 and 56 times the required dose, and no difference was observed between trainees and consultants.19Avidan A. Levin P.D. Weissman C. Gozal Y. Anesthesiologists' ability in calculating weight-based concentrations for pediatric drug infusions: an observational study.J Clin Anesth. 2014; 26: 276-280Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar As another example, the senior leader of a paediatric emergency department confused adenosine with amiodarone, causing an avoidable resuscitation of a child. The institution repeated this real case five times as a simulated scenario involving the original team leader with the same error occurring in four of the five simulations. Although several participants recognized the error, they felt unable to protest because of the hierarchical barrier.20Calhoun A.W. Boone M.C. Porter M.B. Miller K.H. Using simulation to address hierarchy-related errors in medical practice.Perm J. 2014; 18: 14-20Crossref PubMed Scopus (35) Google Scholar This illustrates the importance of accepting and internalizing personal susceptibility to errors for each team member, including hierarchical leaders. Mutual acceptance of fallibility is the basic prerequisite for the implementation of patient safety, as reporting of errors becomes easier and will be perceived as a mandatory aspect of responsible patient care. At the 2010 meeting of the American Society for Patient Safety, it was noted that ‘anaesthesia professionals may exhibit problems with denial’, and an honest and constructive error culture was included in a ‘New Paradigm’ to enhance patient safety.21Eichhorn J.H. Medication safety in the operating room: time for a new paradigm. APSF Summit Conference Proceedings.APSF Newsl. 2010; 25: 1-20Google Scholar We concur with the last sentence of the report by Burton and colleagues1Burton Z. Woodman N. Harvlerode Z. Engelhardt T. Medication errors in paediatric anaesthesia—a cultural change is urgently needed.Br J Anaesth. 2018; 120: 601-603Abstract Full Text Full Text PDF PubMed Google Scholar: ‘It is time for paediatric anaesthesia to embrace a cultural change that allows honest dialogue and encourages learning from mistakes.’ Writing paper: J.K. Revising paper: all authors. None declared. Are anaesthetists resistant to change?British Journal of AnaesthesiaVol. 121Issue 1PreviewEditor—We read with interest the articles in the March 2018 issue of the British Journal of Anaesthesia regarding medication errors in the paediatric population,1–4 and agree with Burton and colleagues3 and Kaufmann and colleagues4 that change should occur. But are we as a specialty resistant to change? Full-Text PDF Open Archive" @default.
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