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

Introduction Medication 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. Objectives To describe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contributory role of individual process step discrepancies to these errors. Methods We conducted a prospective observational study of simulated resuscitations subject to video micro-analysis, 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. Results At least one medication error was observed in every simulated case, and a large magnitude 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. Conclusions Medication 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. Strengths and limitations of this study This study is one of the first to use HRA methods to link task discrepancies with resultant medication errors, as well as to link these discrepancies directly to potential harm. This effort has demonstrated that a significant fraction of the burden of error in the paediatric emergency drug administration process originates during the preparation and administration phase and that most of these errors are likely to be undetected in clinical practice. This study was subject to a number of limitations. Although we went to considerable lengths to replicate the paediatric emergency environment, the simulation environment cannot truly reflect the clinical environment during a genuine emergency. Furthermore, this study was conducted at a single site and participants were not blinded to the purpose of the study, so it is potentially subject to preparation bias. Participants were recruited from the paediatric emergency unit, intensive care unit and general paediatrics ward and had variable experience of emergency cases. However, all participants worked in clinical units that manage critically ill children.