Ensuring Medication Safety for Pediatric Patients in Resource-Limited Settings ,study finds
Medication errors and adverse drug events pose a significant risk for pediatric patients undergoing anesthesia, especially in lower middle-income countries (LMICs) where healthcare systems face resource constraints. A recent study examined the frequency and types of medication errors reported over a 20-year period in the anesthesia department of a tertiary care teaching hospital in an LMIC setting. The researchers reviewed 2,249 critical incident reports filed between 2001 and 2020 for pediatric patients (age 18 or younger) receiving anesthesia care. Of these, 196 incidents involved medication errors. The most common medication classes implicated were neuromuscular blockers (22.5%), opioids (20%), sedatives/hypnotics (15.3%), and antibiotics (13.3%). The majority of medication errors occurred during the administration phase (45%) and the preparation phase (41%). The most frequent types of administration errors were repetition (35%), incorrect dosing (33%), and medication substitution (23%). About one-third of administration errors resulted in harm to the patient, with 15 incidents classified as "serious", 11 as "significant", and 1 as "life-threatening". Notably, 92% of the medication errors involved human factors, with the most common contributors being lack of mandatory checks, poor judgment, and knowledge gaps (48%), as well as deviations from standard practice (29%). Other human factors implicated included stress (12.2%) and poor communication (10.5%).
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