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October 23, 2017
43031.541667 - 43031.625
Room Exhibit Hall B2 - Area C
Sustained Reduction of Medication Errors With the Anesthesia Medication Template
Eliot Grigg, M.D., Lizabeth D. Martin, M.D., Axel Roesler, Ph.D., Faith J. Ross, M.D., Sally E. Rampersad, M.B., Lynn D. Martin, M.D.
University of Washington / Seattle Children's Hospital, Seattle, Washington, United States
Disclosures: E. Grigg: None. L.D. Martin: None. A. Roesler: None. F.J. Ross: None. S.E. Rampersad: None. L.D. Martin: None.
Background Medication errors are a significant source of morbidity in anesthesia, and the anesthesia medication process is vulnerable to single-point failures and lacks a formal organizational strategy. A group of anesthesiologists and design professors at the University of Washington employed formal design and human interaction theories to create the Anesthesia Medication Template (AMT) to organize medications in the anesthesia workspace and to reduce cognitive errors.

Methods Medication errors were self-reported at Seattle Children’s Hospital from March 2012-December 2016, and the template was deployed in all anesthetizing locations in August of 2013. Errors were categorized by type and the three relevant to the AMT are reported here: (1) syringe swaps, (2) miscalculation errors, and (3) all errors resulting in at least moderate, temporary harm. Errors were graphed over time using quality improvement methods because they were too infrequent for a meaningful logistic regression. First, the days between errors were graphed over the study period, and second, the instantaneous annual error rates were calculated for syringe swap and miscalculation errors in control charts.

Results Figure 1 shows the days between errors of swap, miscalculation, harm errors and near misses, and the red arrow indicates the implementation of the AMT. Figure 2 shows the annual rate of syringe swap errors over time, and the average annual error rate dropped from 22.1 to 9.8 errors per year after AMT implementation. Figure 3 shows the annual rate of miscalculation errors, and the average rate dropped from 8.5 to 1.2 errors per year after AMT implementation. Near miss errors were reported consistently over the study period (6 in the year prior and an average of 5 per year for the two years after) suggesting that reporting fatigue was not responsible for the error reduction. By the end of the study the last syringe swap, miscalculation and harm errors were 783, 674 and 393 days ago respectively.

Conclusion The AMT has nearly eliminated syringe swaps and miscalculation errors at Seattle Children’s Hospital over its first 2.5 years in use and is associated with a reduction of medication-related harm. The AMT is an example of applying formal design principles to patient safety, and it has the potential to greatly reduce medication errors at other institutions by reducing cognitive load during anesthesia.

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