Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study

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Abstract

BACKGROUND:

Medication errors continue to be a significant source of patient harm in the operating room with few concrete countermeasures. The organization and identification of medication syringes may have an impact on the commission of medication errors in anesthesia, so a team of physicians and designers at the University of Washington created the Anesthesia Medication Template (AMT) to define a formal way of organizing the anesthesia workspace. The purpose of this study is to assess the ability of the AMT to reduce perioperative medication errors by anesthesia providers.

METHODS:

This study evaluated the AMT in 2 phases: (1) 41 anesthesia providers administered medications in 2 prospective, randomized operating room simulations with or without the AMT, while medication errors were directly observed; and (2) around 200 providers prospectively self-reported medication errors from all anesthetizing locations during a 2-year period at Seattle Children’s Hospital, an academic, pediatric medical center.

RESULTS:

In simulated emergencies, the odds of medication dosing errors using the AMT were 0.21 times the odds of medication dosing errors without AMT (95% confidence interval [CI], 0.07, 0.66), controlling for scenario, session, training level, and years at training level. During the year after implementation of the AMT, the mean monthly error rate for all reported medication errors that reached patients decreased from 1.24 (95% CI, 0.85–1.79) to 0.65 (95% CI, 0.39–1.09) errors per 1000 anesthetics. The mean monthly error rate of reported swap, preparation, miscalculation, and timing errors decreased from 0.97 (95% CI, 0.64–1.48) to 0.35 (95% CI, 0.17–0.70) errors per 1000 anesthetics. Medication errors that resulted in patient harm did not change after implementation of the AMT.

CONCLUSIONS:

Standardizing medication organization with the AMT is an intuitive, low-cost strategy with the potential to improve patient safety through reducing medication errors by anesthesia providers.

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