QuestionCan you summarize this article in 1 paragraph of 200 to 220 words? Summary of: Research prob

QuestionCan you summarize this article in 1 paragraph of 200 to 220 words? Summary of: Research problem; Description of research process; Results of study. www.aana.com/aanajournalonline AANA Journal   August 2021   Vol. 89, No. 4 319Anesthesia providers are regularly responsible forassessing, diagnosing, and determining pharmacologictreatment of a problem. This critical workflow oftenincludes medication preparation. Decision making inanesthesia frequently requires rapid intervention, andcaring for the pediatric population poses additionalchallenges, such as needing to quickly calculate theweight-based dosing of medications. The objective ofthis review article was to identify and describe themesrelated to pediatric medication errors associated withanesthesia. Additional goals of the review consistedof identifying and comparing various error reductionstrategies with a primary goal of communicating themost effective methods to reduce medication errorsin the pediatric population. Screening criteria wereset, and 17 published scholarly articles meeting inclusioncriteria were evaluated using a systematic process.Common themes found leading to medicationerrors were incorrect dosing, incorrect medication,syringe swap, wrong patient, and wrong dosing interval.The most valuable and sustainable error reductionstrategies found were standardized labeling, prefilledsyringes, and 2-person medication checks. It is believedthat this review will expound on the factors that canbe controlled or minimized to decrease the incidenceof anesthesia-related pediatric medication errors andfacilitate implementation of risk mitigation strategiesimmediately into clinical practice.Keywords: Anesthesiology, intraoperative pediatric medicationerrors, pediatric anesthesia errors, pediatric drugerrors, pediatric medication error reduction strategies.Pediatric Medication Errors and ReductionStrategies in the Perioperative PeriodJennifer L. Bekes, MS, CRNACourtney R. Sackash, MS, CRNAAshley L. Voss, MS, RNChristopher J. Gill, PhD, MBA, CRNAAccording to the US Food and Drug Administration(FDA), medication errors cause anestimated 1.3 million injuries each year inthe United States, accounting for 1 deathevery day.1 Medication error is defined as”failure in the drug to treatment process that leads to,or has the potential to lead to, harm to the patient andincludes an act of omission or commission (drug notadministered or administered late), substitution (incorrectdrug administered instead of intended drug), repetition(extra dose of intended drug given), incorrect dose(incorrect concentration, amount, or rate of infusion ofthe drug administered), insertion (drug administeredthat was not attended at that time or at any stage), andincorrect route.”2 Medication errors are of concern inthe pediatric population due to the devastating implicationsfor patients and are more likely to be life threateningin the pediatric population than in most adults. Theincreased risk in the pediatric population is due to theunderdevelopment of their metabolism, which can affectmedication clearance. Also, because of children’s smallersize, the need for meticulous calculation for weight-baseddosing can lead to medication errors.3 Medication errorsnot only can have devastating effects on the patient butalso can have distressing effects on the provider. Perioperativemedication errors in the pediatric population byanesthesia providers are a major concern, and reductionstrategies are an ongoing challenge.To formulate strategies to help reduce the occurrenceof medication errors, one needs to first identify the mostcommon perioperative medication errors. The purpose ofthis study was to perform a narrative literature review tocharacterize the frequency, type, and outcome of anesthesiamedication errors among pediatric patients over thepast 10 years. In this review we also sought to describesuccessful error reduction strategies described in the literature.Our research questions were: What are the maintypes of medication errors in the pediatric population aged1 day to 18 years in the perioperative period? What mitigationstrategies have had the best outcomes that can beimplemented in our current anesthetic pediatric practice?MethodsWe conducted a narrative literature review on the topicof perioperative medication errors and reduction strategiesin the pediatric population by anesthesia providers.Multiple search engines were used to find articlespertinent to this topic, including PubMed, CumulativeIndex to Nursing and Allied Health Literature (CINAHL),Google Scholar, MEDLINE, the Cochrane Library, andClinicalKey databases. We considered relevant articlespublished between January 1, 2009, and July 15, 2019.320 AANA Journal   August 2021   Vol. 89, No. 4 www.aana.com/aanajournalonlineWe defined perioperative period using the definition ofGoodman and Spry4: “The perioperative period beginswhen the patient is informed of the need for surgery, includesthe surgical procedure and recovery, and continuesuntil the patient resumes his or her usual activities. Thesurgical experience can be segregated into three phases:(1) preoperative, (2) intraoperative, and (3) postoperative.The word ‘perioperative’ is used to encompass allthree phases.” Study inclusion criteria consisted of a targetpopulation from 1 day to 18 years of age, articles printedin the English language, full-text publications, with medicationerrors and medication error reduction strategiesperformed by anesthesia providers and occurring in theperioperative period. Exclusion criteria included studiesnot published in English, not a full-text publication, didnot take place in the perioperative period, did not involvethe pediatric population of our specified age range, anddid not involve anesthesia providers.We identified search terms relevant to pediatric medicationerrors and reduction strategies perioperatively.The following search query was adapted to each databaseand was used to retrieve articles: pediatric medicationerrors AND pediatric medication reduction strategies ANDpediatric perioperative medication errors AND pediatricanesthesia errors AND intraoperative pediatric medicationerrors. After our original search found 17 articles thatmet the inclusion criteria, we manually searched thereferences from the most applicable articles. Articles thatwere not published within the last 10 years, took placeoutside the perioperative phase, or did not relate to pediatricanesthesia were excluded. After these articles wereexcluded, our search generated 18 articles.The articles were scored using the Critical AppraisalSkills Programme Qualitative Checklist.5 This tool waschosen because it breaks down the methodologic approachto qualitative research into 10 detailed questions,which we used as a guide to thoroughly determine thequality of each article. There were 10 questions used toscore each article on its quality. If the question was answered”yes” a score of 1 was given, “can’t tell” was givena zero, and “no” was given a zero. If the article achieveda score of 5 of 10, the article was considered of sufficientquality. After scoring each article, 1 was discarded, yielding17 remaining articles. Data were extracted on thesetting, intervention, problem, and major findings associatedwith pediatric medication errors with reductionstrategies in the perioperative period involving anesthesiaproviders. A PRISMA flow diagram represents an illustrativeflow of the references analyzed in the developmentof our narrative literature review (Figure). Finally, the 17articles were reviewed and organized into themes.ResultsA summary of the medication errors evaluated is includedin Table 1. A summary of the most common errorreduction strategies appears in Table 2.• Data Analysis. We first determined each medicationerror discovered in each article and then calculatedFigure. PRISMA Flow DiagramAbbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; PRISMA, Preferred Reporting Items for SystematicReviews and Meta-Analyses.www.aana.com/aanajournalonline AANA Journal   August 2021   Vol. 89, No. 4 321a percentage to determine which errors occurred mostoften. After a review of the articles in our study, 70%(12 of 17 articles) reported medication errors involvingincorrect dosing,1-3,6-14 35% (6/17) were related toincorrect medication,2,3,8,10,15,16 29% (5/17) were relatedto syringe swap,1,6,10,11,16 17% (3/17) were inappropriatemedication labeling,2,11,15 and 6% (1/17) were related toa known allergen3 (see Table 1).The causes of the incorrect dosing were noted to befrom incorrect dilution of a medication and errors incalculation of the dose. In regard to children, calculatingthe proper weight-based dose is critical, and the errorsfrom miscalculation can be fatal. The primary cause ofsyringe swap was having a medication manufacturedwith similar labels. Various medications have the samecolor and design, such as ondansetron and phenylephrine.The outcome of swapping these medications can beand has proved to be fatal. For example, an 11-year-oldboy underwent general anesthesia to drain an abscess ofthe ankle.10 While the patient was under anesthesia, theanesthesia provider administered what was thought wasondansetron; however, the provider mistakenly administereda concentrated 1-mL ampule of phenylephrine. Asa result, this patient experienced a fatal heart arrhythmiafollowing the administration of the phenylephrine.Unfortunately, these vials look similar and were mistakenfor one another, which cost a life in this tragic instance.10High stress, fatigue, and distractions are found to be contributingfactors that also can cause medication errors.• Outcome Measures. Our outcome measures includedthe common themes found among the mostcommon medication errors made. One of the mostcommon themes found among medication errors wasincorrect dosing of the medication due to calculationerrors. Calculation errors were found to most frequentlyoccur during the dilution of a medication. The secondmost common theme found was the administration ofan incorrect medication. For example, ondansetronand phenylephrine have similar-appearing vials, whichmay cause one to be administered instead of the other,intended medication, ultimately leading to a medicationerror.10 The remaining common themes found leadingto medication errors were syringe swap, wrong patient,and wrong dosing interval.2 This information, along withidentified characteristics that make the pediatric populationmost at risk, led to the formulation and implementationof medication error reduction. The implementationof medication error reduction strategies was evidenced tohelp reduce medication errors and improve safety in thepediatric population.Table 1. Medication Errors in Pediatric Population During Perioperative PeriodExample of Examples identified in Percentage of each errormedication errors original texts compiled from our researchIncorrect dose Dilution errors, calculation errors, incorrect interval 77Incorrect medication Phenylephrine vs ondansetron, similar looking ampules, 35similar sounding namesSyringe swap Same color syringe, same size, same design, 29neostigmine vs succinylcholineInappropriate medication labeling No label, no name, no concentration, wrong units, 17illegible, content differs from label, inconsistent labellocation, similar labelingKnown allergen Distraction, interruption, fatigue 6Table 2. Medication Error Reduction Strategies in Pediatric Population During Perioperative PeriodExample of error Percentage of effective error reductionreduction strategy strategies compiled from our researchStandardized labeling 65Prefilled syringes 53Two-person check 41Drug library/electronic-based references 35Quality improvement safety analytics 35Pharmacy support 29Computer check system 24Educating staff 17Standardized anesthesia workspace 12Zero-tolerance philosophy 12Checklist 6322 AANA Journal   August 2021   Vol. 89, No. 4 www.aana.com/aanajournalonlineOur outcome measures also included the variousmedication error reduction strategies that were implementedin each study. From the literature review, standardizedlabeling was found to be the most effective errorreduction strategy,2,6,8-13,15-17 followed by prefilled syringes.2,3,7,8,10,12-14,17 Other error reduction strategies included2-person check,2,3,10,11,13,14,17 using a drug library/electronic-based references,2,3,7,8,12,17 using quality improvementand safety analytics,3,6,8,17-19 using pharmacysupport,3,6,7,10,13 using a computer check system,3,8,15,16articles educating staff,2,17,19 using a standardized anesthesiawork space,11,17 using a zero-tolerance philosophy,3,8and using a checklist9 (see Table 2). A zero-tolerancephilosophy is generally considered to include a meetingin which practitioners who have not followed the institution’spolicy for medication administration can providean explanation in an effort to help the team understandthe problems involved. These meetings generally takeplace with the chief practitioner and provide opportunityfor the chief to identify potential unsafe behaviors by thepractitioner involved in the incident, which may possiblylead to consequences. The goal of this philosophy is ensuringpatient and practitioner safety.3• Error Reduction Strategies Supported by LiteratureReview. Patient safety is of utmost priority, and theNational Academy of Medicine (formerly called theInstitute of Medicine) is seeking strategies to preventmedication errors from occurring. Although anesthesiais among the leaders in patient safety, research findingssuggest that high medication error rates in this fieldof practice still exist.11 Studies have found medicationerrors to be responsible for more than 80% of scenariosthat cause patient harm, and nearly all these scenarioswere considered to be preventable.6Throughout our research, themes were recognizeddescribing the various medication errors routinely seenduring the perioperative period. The addition of pharmacysupport, a checklist, 2-person verification, pediatricanesthesia drug library on infusion pumps that includesdose ranges and forcing functions to double-check thepatient’s weight and appropriate dosages, and a zerotolerancephilosophy are some error reductions strategiesthat have been executed.1,3,9 Several of these medicationerror reduction strategies were implemented throughoutvarious institutions nationwide and found to be effective.The most valuable and sustainable error reductionstrategies found were standardized labeling, prefilledsyringes, and 2-person medication checks. Standardizedlabeling should be clearly identifiable. One way this canbe achieved is by using a specific color for specific drugtypes. An example provided in one of the articles is thatopioid medications were color coded with light-bluelabels.17 An additional way to achieve standardization oflabels is through a distinguishable font. A distinguishablefont includes font size and style for ease of readability. Inaddition, having clear organization of the wording on thelabel helps providers differentiate between medications.Label placement is also important, and it was found thathaving it lengthwise on the syringe helps improve medicationidentification. By performing lengthwise label placement,studies have shown that there is likely a reducedrate of syringe swap and medication errors relating to adecrease in cognitive load.11 The FDA has changed itsstandards over the last decade on the labeling of medications.Because of these changes, hospitals are now incorporatingbar codes in their labels for all drugs and biologics.Incorporating bar codes and medication labels is asafety measure used to ensure the correct patient receivesthe correct medication at the correct time.15The second most valuable and sustainable error reductionstrategy was prefilled syringes. According to Shawand Litman16: “Prefilled syringes can be prepared eitherat the drug manufacturer’s site of production, by a thirdpartymedication distribution centre, or by a hospitalpharmacy under similarly accurate and sterile conditions.”The theory behind prefilled syringes is that theyeliminate errors that come from provider preparationduring the reconstitution and dilution of medicationsand they provide the most accurate dose of medication.Also, in an emergency situation, prefilling syringesmakes medications more readily accessible and reduceserrors that are associated with providers preparing medicationsunder stress. Although higher costs and limitedshelf life are disadvantages to pre-prepared syringes,the quality controls completed during their preparationmake these medications more precise and help reducethe rate of medication errors.17The third valuable and sustainable error reductionstrategy found was performing a 2-person check beforeadministration of medication. These checks are completedby 2 individuals separately confirming the 5 rightsof medication administration. These 5 rights are the rightpatient, medication, dose, route, and time. Two-personchecks vs single-person checks were found as an effectivemethod for preventing medication errors.DiscussionPediatric medication errors occur in the perioperativesetting for various reasons. Limitations of the studiesinclude in this review involved data coming from a voluntaryreporting system and manual chart review. Thismakes it difficult to establish the true rate of medicationerrors. Another limitation is implementing these reductionstrategies at facilities nationwide and not just at specifichospitals. These medication errors are most likelyunderreported because of the fear of repercussions andunawareness of errors. Some of the factors that preventhealthcare providers from reporting medication errors isthe fear of responses from patients, patients’ family, physicians,and administration. Specifically, there is fear ofwww.aana.com/aanajournalonline AANA Journal   August 2021   Vol. 89, No. 4 323a negative attitude being developed toward the provideror the possibility of being sued. Developing a supportiveatmosphere and adopting a no-punishment approach tomedication errors have been shown to help improve selfreporting.In addition, a simplified reporting process forhealthcare providers that is easy and convenient to usehas been shown to improve self-reporting. The reportingof medication errors is important to identify reoccurringerrors so they can be corrected and help improve overallpatient safety.20 Due to these limitations and factors,the estimate of the frequency of errors is not accurate.Research has shown an improvement in the incidenceof pediatric medication errors with the implementationof various error reduction strategies. We believe as morequality improvement and safety analyses are conductedregarding pediatric medication errors in the perioperativesetting, the incidence of errors will continue to decline.After reviewing each article, we found that standardizedlabeling was the most effective reduction strategy, followedby prefilled syringes. The quality controls that are preparedon pre-prepared, labeled, and sealed syringes that comefrom either the pharmaceutical industry or the hospitalpharmacy make the use of that medication more accurate,effectively reducing medication error rates. The limitationof pre-prepared syringes is the restricted shelf life andassociated higher costs.17 Another limitation to error reductionis lack of self-reporting. This makes it difficult todetermine the exact cause, how often errors are occurring,and where the gap lies in working to prevent such errors inthe future. Furthermore, the level of implementation andacceptance of altering everyday practice with new policiesand recommendations relies on how overburdened thehealthcare providers feel with such changes.17Additional research needs to be completed regardingmedication error reduction strategies that have beeneffective and to find ways to successfully implementreduction strategies into current everyday practice. Theimplementation of these error reduction strategies wouldreduce the rate of current errors and prevent new errors,which would improve the overall quality and safety of theperioperative environment for the pediatric population.Suggested areas for future work should be based onusing methods for data collection other than self-reporting.Self-reporting leads to inaccurate data due to lack ofproviders disclosing their medication errors. A solutionsuggested is for providers to report all medication errors,not only those that cause patient harm. Furthermore,another recommendation is to have future studies conductedusing a culture of no-blame drug error reportingand review system. Another method proposed was to usea retrospective chart review. It is important for the medicationerror reduction strategies discovered to be standardizedand implemented nationwide vs at select individualhospitals. After implementation of these strategies, furtherstudies should be performed to see if results can be generalized.Additionally, after medication error reductionstrategies are put into effect, if errors continue to occur, itis suggested to expand research at a more individual basisregarding provider fatigue, burnout, and supervision.REFERENCES324 AANA Journal   August 2021   Vol. 89, No. 4 www.aana.com/aanajournalonlineAUTHORSJennifer L. Bekes, MS, CRNA, is a Wayne State University Nurse Anesthesiaprogram graduate. She was a student when this article was written andnow practices anesthesia in Bingham Farms, Michigan.Courtney R. Sackash, MS, CRNA, is a Wayne State Nurse Anesthesiaprogram graduate. She was a student when this article was written andnow practices anesthesia in Mount Clemens, Michigan.Ashley L. Voss, MS, RN, is a Wayne State University Nurse Anesthesiaprogram graduate. She was a student at the time this article was written.Christopher J. Gill, PhD, MBA, CRNA, is an assistant professor (clinical)in the Wayne State University Nurse Anesthesia program.DISCLOSURESName: Jennifer Bekes, MS, CRNAContribution: This author made significant contributions to the conception,synthesis, writing, and final editing and approval of the manuscriptto justify inclusion as an author.Disclosures: None.Name: Courtney Sackash, MS, CRNAContribution: This author made significant contributions to the conception,synthesis, writing, and final editing and approval of the manuscriptto justify inclusion as an author.Disclosures: None.Name: Ashley Voss, MS, RNContribution: This author made significant contributions to the conception,synthesis, writing, and final editing and approval of the manuscriptto justify inclusion as an author.Disclosures: None.Name: Christopher Gill, PhD, MBA, CRNAContribution: This author made significant contributions to the conception,synthesis, writing, and final editing and approval of the manuscriptto justify inclusion as an author.Disclosures: None.The authors did not discuss off-label use within the article. Disclosurestatements are available for viewing upon request.Copyright of AANA Journal is the property of American Association of Nurse Anesthetistsand its content may not be copied or emailed to multiple sites or posted to a listserv withoutthe copyright holder’s express written permission. However, users may print, download, oremail articles for individual use.Health ScienceScienceNursingNUR 282Share Question

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