A Perioperative Systems Improvement program, put into place to review and respond to medication errors, has resulted in significant improvements at Boston Children’s Hospital.
In an effort to decrease adverse medical events caused by drug administration errors, researchers there conducted a retrospective analysis of errors made from 2008 through 2016. Information was obtained from mandatory error reports incorporated into the anesthesia medical record and from manual chart review. The study characterized the type, severity and frequency of anesthetic medication errors during the 8.5-year period. Additionally, the team examined root causes of the errors and developed a targeted error reduction program.
“Part of my role is oversight of quality improvement programs for the department,” said Izabela Leahy, MS, BSN, RN, executive director of the Department of Anesthesiology, Perioperative and Pain Medicine at Boston Children’s Hospital, and co-author of the study.
Among the 287,908 cases evaluated during the study period, 105 medication errors were identified. The most common errors were incorrect dose (55.2%) and incorrect medication (27.6%). After implementation of the medication safety program in 2009, the hospital saw a yearly reduction in annual medication error rates.
“We established the Perioperative Systems Improvement committee, which currently consists of 35 clinicians,” Ms. Leahy said. “Each event in question is reviewed by three anesthesiologists who review medical records, interview those involved, then as a committee develop suggestions to make improvements.
“Initially, we had errors [made] by attendings, fellows and residents. Since implementation of the program, the only errors have been by residents. This shows the education works.”
Robert Brustowicz, MD, assistant professor of anesthesia at Harvard Medical School, in Boston, and a co-author, noted that the gradual decline in errors was very consistent. “The one blip,” he said, “occurred when we took over the anesthesia services in the radiation suites. We found that the infusion pumps were different [from] those we were using in the [operating room].” Once the pumps were standardized, these problems declined.