British Journal of Anaesthesia, 120 (3): 563e570 (2018)

doi: 10.1016/j.bja.2017.12.014
Advance Access Publication Date: 1 February 2018
Quality and Patient Safety

Incidence, characteristics, and predictive factors for

medication errors in paediatric anaesthesia: a
prospective incident monitoring study
C. Gariel1, B. Cogniat1, F.-P. Desgranges1, D. Chassard1,2 and L. Bouvet1,2,*
1
Department of Anaesthesia and Intensive Care, Femme Me re Enfant Hospital, Hospices Civils de Lyon,
2
 Claude Bernard Lyon 1, Villeurbanne, France
Bron, France and University of Lyon, Universite

*Corresponding author. E-mail: lionel.bouvet@chu-lyon.fr.

This article is accompanied by an editorial: How to prevent medication errors in the operating room? Take away the human factor by R.S.
Litman, Br J Anesth 2018:120:438e440, doi:10.1016/j.bja.2018.01.005.

Abstract
Background: Medication errors are not uncommon in hospitalized patients. Paediatric patients may have increased risk
for medication errors related to complexity of weight-based dosing calculations or problems with drug preparation and
dilution. This study aimed to determine the incidence of medication errors in paediatric anaesthesia in a university
paediatric hospital, and to identify their characteristics and potential predictive factors.
Methods: This prospective incident monitoring study was conducted between November 2015 and January 2016 in an
exclusively paediatric surgical centre. Children <18 yr undergoing general anaesthesia were consecutively included. For
each procedure, an incident form was completed by the attending anaesthetist on an anonymous and voluntary basis.
Results: Incident forms were completed in 1400 (73%) of the 1925 general anaesthetics performed during the study period
with 37 reporting at least one medication error (2.6%). Drugs most commonly involved in medication errors were opioids
and antibiotics. Incorrect dose was the most frequently reported type of error (n¼27, 67.5%), with dilution error involved
in 7/27 (26%) cases of incorrect dose. Duration of procedure >120 min was the only factor independently associated with
medication error [adjusted odds ratio: 4 (95% confidence interval: 2e8); P¼0.0001].
Conclusions: Medication errors are not uncommon in paediatric anaesthesia. Identification of the mechanisms related to
medication errors might allow preventive measures that can be assessed in further studies.

Keywords: anaesthesia; general; errors; medication; paediatrics

Medication errors are an all too common occurrence in medication errors varies considerably among studies,
hospitalized patients that can lead to severe, but preventable, depending on the definition used and care setting.2,3 Several
iatrogenic harm.1 In the paediatric population, the rate of studies have been performed regarding drug administration

Editorial decision: December 10, 2017; Accepted: December 10, 2017

© 2017 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

563
 564 - Gariel et al.
Editor’s key points
 A prospective indent monitoring study was performed
at a single French paediatric hospital to determine the
rate and nature of medication errors in paediatric
patients.
 At least one medication error was reported in 2.6% of
1400 case reports (one per 38 cases) frequently involving
incorrect dose or dilution errors, most commonly
involving administration of opioids or antibiotics.
 Identification and mitigation of the factors contributing
to this high error rate is necessary.
and medication errors during anaesthesia in adults.4e9
Rates of medication errors ranged from 1/900 to 1/130 anaes-
thetic procedures, with one error occurring for every 20 peri-
operative medication administrations.6,8,10 The most frequent
medication errors are substitution, incorrect dose or omission,
and main factors reported as contributing to errors are haste
or pressure to proceed, distraction, and inattention.4,7 Surgical
case type, patient physical status, and level of provider expe-
rience may also play a role in the adult.4,7
Epidemiology of medication errors has been less assessed
in paediatric anaesthesia. Weight-based dosing calculations
and use of several drug dilutions can lead to increased risk for
medication errors in this setting. In a recent retrospective
analysis, the most frequent medication error was adminis-
tration of an incorrect dose, which would have been prevent-
able in almost all cases.11 We performed a prospective single
centre incident monitoring study to determine the incidence
and characteristics of medication errors in a university pae-
diatric hospital.
Methods
Design and approval
This prospective study was conducted between November 3,
2015 and January 31, 2016 after approval from the institutional
review board (Comite  de Protection des Personnes Sud-Est II,
IRB number 00009118). The methodology followed the rec-
ommendations of the STrengthening the Reporting of Obser-
vational studies in Epidemiology (STROBE) statement.12 The
study was performed in the nine operating rooms of a large
university paediatric hospital in Lyon, France. Surgical cases
encompass a full spectrum of surgical care, except cardiac
surgery, and represent about 9000 surgical procedures per
year. We prospectively enrolled all consecutive children aged
<18 yr undergoing general anaesthesia during the study
period.
Organization of anaesthetic care
The anaesthetic team was composed of a senior anaesthetist
and a nurse anaesthetist. Trainees in anaesthesia may take part
in the procedure, as resident anaesthetists, student nurse
anaesthetists or both. For each anaesthetic procedure, the
nurse anaesthetist prepares the drugs according to the senior
anaesthetist’s prescription. All drugs are prepared in the oper-
ating room or in the recovery room from the vial or ampoule; no
prefilled syringes are used. Each syringe and bottle for infusion
should be labelled, using whenever possible a coloured label
according to the pharmacological class in accordance with
international colour coding.13e15 These labels are provided by
the manufacturer for some drugs, and rolls of coloured adhesive
labels were also available in each operating room and recovery
room (blue for opioids, yellow for i.v. induction agents, orange
for benzodiazepines, violet for vasopressors, red for neuro-
muscular blocking agents, and uncoloured for other drugs)
when no label was provided by the manufacturer. The practi-
tioner should write the name of the drug drawn into the syringe
(if not pre-printed) and the dilution with the unit on the label,
according to French guidelines and the recommendations of the
French National Authority for Health.16
Nurse and senior anaesthetists are both able to manage the
airway, to insert peripheral venous access and to inject drugs,
according to the senior anaesthetist’s prescription. Only the
senior anaesthetist can perform regional anaesthesia. In the
recovery room, drugs were administered by a registered nurse,
according to the prescription of the senior anaesthetist in
charge of the patient. Medications administered and medical
acts performed are all manually recorded or selected into a
pre-defined list within the computerized anaesthesia file of
each patient.
Definitions
Medication error was defined as a ‘failure in the drug treat-
ment process that leads to, or has the potential to lead to,
harm to the patient and includes an act of omission or com-
mission’.17,18 Medication error can be related to omission (drug
not administered or administered late), substitution (incorrect
drug administered instead of intended drug), repetition (extra
dose of intended drug given), incorrect dose (incorrect con-
centration, amount, or rate of infusion of the drug adminis-
tered), insertion (drug administered that was not attended at
that time or at any stage), and incorrect route.4,6
Protocol
Before the beginning of the study, all the members of the
anaesthesia department (senior anaesthetists, nurse anaes-
thetists, and recovery room nurses) received comprehensive
information as to the significance and aims of the study, def-
initions of terms for data collection, and were encouraged to
participate in the study. Posters were displayed in each oper-
ating room and in the recovery room to remind practitioners to
complete and submit their forms.
During the study period, for each patient undergoing a
procedure under general anaesthesia, the senior anaesthetist
in charge of the patient completed an incident form before
discharge of the patient from the recovery room, according to
their observations and to statements of the nurse anaesthe-
tist, recovery room nurse, and, if any, trainees, regarding
occurrence of any medication error during the procedure or in
the recovery room. Incident forms were designed to elicit both
voluntary and anonymous responses as to the occurrence or
not of a medication error, the type of medication error, the
drug involved, the member of the team responsible for the
error, the place the medication error occurred (operating
theatre or recovery room), mechanisms of the error, and its
consequences for the patient. Factors that may have contrib-
uted to the medication error were also recorded, including
disturbance, pressure to proceed related to emergency, fa-
tigue, preparation and administration by two distinct pro-
fessionals, lack of standardization for dilution, similar
packaging, and other. Factors potentially associated with

Fig 1. Study flow.
medication errors were also collected: patient’s age and body
weight; ASA physical status; duration of procedure; elective or
emergency procedure; number of people in charge of anaes-
thesia; anaesthesia performed either during night (between
00:00 and 07:59 h) or day (between 08:00 and 23:59 h); regional
anaesthesia combined with general anaesthesia; and indica-
tion for general anaesthesia [visceral, thoracic and urological
surgery, orthopaedic surgery, cephalic surgery (including ear
nose and throat surgery, maxillofacial surgery, neurosurgery
and ophthalmological surgery), other procedures including
endoscopic procedure and central venous catheter insertion
out of the context of any surgery]. Incident forms were
collected daily and data were entered into a Microsoft® Excel
spreadsheet for further statistical analysis.
Statistical analysis
Distribution of continuous variables was tested for normality
using the KolmogoroveSmirnov test. Continuous variables
were expressed as median and inter-quartile range (IQR), and
categorical variables as number [percentage and 95% confi-
dence interval (CI) according to the Wilson method with con-
tinuity correction]. Statistical comparisons were performed
using the c2 test or Fisher exact test for qualitative data and
the ManneWhitney U-test for quantitative data. The study
population was divided into two groups according to occur-
rence (Medication error group) or not (No medication error
group) of at least one medication error during the anaesthetic
procedure or in the recovery room. Univariate and
Medication errors in paediatric anaesthesia - 565
multivariate logistic regression analyses were used to identify
variables associated with occurrence of at least one medica-
tion error during the anaesthetic procedure or in the recovery
room, producing odds ratios (OR) with 95% CI. For multivari-
able model building, all variables associated in univariate
analysis (P<0.2) with the occurrence of at least one medication
error were subjected to a backward logistic regression anal-
ysis. For the purpose of the analysis, quantitative variables
were categorized as dichotomous (yes or no) according to the
optimal threshold value chosen using receiver operating
characteristic curve analysis (i.e. the value that maximizes the
sum of sensitivity and specificity). Goodness of fit of the
multivariate model was assessed using the Hos-
mereLemeshow test. All analyses were performed using
MedCalc® version 12.1.4.0 for Windows (MedCalc Software,
Ostend, Belgium) using a two-sided type 1 error rate of 0.05 as
the threshold for statistical significance.
Results
A total of 1925 anaesthetic cases were performed during the
study period that met inclusion criteria. Reporting forms were
completed in 1400 patients for a response rate of 73% (Fig. 1).
General anaesthesia was associated with regional anaesthesia
in 395 (28%) patients. Characteristics of the population and
indications for general anaesthesia are presented in Table 1.
Forty errors were reported in 37 children. Three forms re-
ported two errors during the same case. The rate of anaes-
thesia with at least one medication error was 2.6% (95% CI:
 566 - Gariel et al.

0.8e7.3%), corresponding to 1/38 anaesthetic procedures with

at least one error. Considering the three cases that had two Table 2 Drugs involved in the 40 medication errors recorded
during the study period. Data are presented as n (%)
errors, the overall rate of medication errors was 2.9% (95% CI:
0.9e7.6%) per case.
Drug n (%) Drug involved (number
of medication errors reported)
Characteristics of the medication errors
Opioids 10 (25) Alfentanil (5), remifentanil (3),
The drugs involved in the medication errors are shown in sufentanil (1), morphine (1)
Table 2. All medication errors but one (97.5%) occurred in the Antibiotics 8 (20) Cefazoline (3), ceftriaxone (1),
operating theatre, and one medication error occurred in the cefotaxime (1), cefuroxime (1),
amoxicillineclavulanate (1),
recovery room. Ten (25%) errors involved i.v. medications
amikacin (1)
infused using a syringe pump, 19 (47.5%) i.v. medications
Analgesics 5 (12.5) Paracetamol (5)
continuously infused without a syringe pump, 10 (25%) i.v. i.v. fluids 5 (12.5) Ringer’s lactate
drug bolus injections, and one (2.5%) administration of local (2), NaCl 0.9% (1),
anaesthetic by the surgeon for wound infiltration. mannitol (1), bicarbonates
Incorrect dose was the most frequently reported error 4.2% (1)
Hypnotics 3 (7.5) Propofol (2), ketamine (1)
(n¼27, 67.5%). It was related to intentional administration of a
Vasopressors 3 (7.5) Epinephrine (1),
wrong dose in two patients and to error in dose calculation in
norepinephrine (1),
25 patients. Inadequate communication (lack of communica- ephedrine (1)
tion between practitioners, discrepancy between directive or Antifibrinolytics 3 (7.5) Tranexamic acid (3)
information relating to medication verbally given by a practi- Anti-emetics 2 (5) Ondansetron (2)
tioner and what was understood by another, or both), and Local anaesthetics 1 (2.5) Ropivacaine (1)
inadequate setting of syringe pump each accounted for 20% of
medication errors (Table 3).

tachycardia and hypertension as a result of accidental

Contributing factors
The main factor reported as contributing to medication errors
was disturbance during the anaesthesia procedure (n¼10, 25%
of medication errors). Others contributing factors were prep-
aration and administration by two distinct professionals (n¼7,
17.5% of medication errors), and non-standardized practice
among practitioners as to dilution of the drug [n¼7, 17.5% of
medication errors corresponding to 7/27 (26%) of dosing er-
rors]. Pressure to proceed and fatigue were reported as
contributing factors in two cases each (5% of errors each). No
contributing factor was identified for nine (22.5%) errors.
Clinical consequences
Medication errors had clinical consequences in three patients.
Two infants aged <1 yr experienced low blood pressure
(because of insufficient vascular filling that was only 3.5 ml
kg1 h1 during 40 min instead of 10 ml kg1 h1,for one infant;
and related to high dose of opioids for the other infant),
resolved with i.v. fluids. One child aged 7 months experienced
administration of 300 mg of epinephrine in an unlabelled sy-
ringe that the senior anaesthetist thought was saline solution,
with vital signs returning spontaneously to normal in 5 min.
No deaths or irreversible harm occurred, neither major
morbidity nor prolonged hospitalization.
Factors associated with medication errors
Duration of surgery was significantly associated with medi-
cation errors in univariate analysis (Table 4). According to
multivariate analysis, duration of operating room time >120
min was the only factor independently associated with
increased risk for medication error (Table 5).
Discussion
In this single centre prospective observational study con-
ducted in a paediatric surgical centre, the rate of anaesthetic
Table 3 Characteristics of the 40 medication errors recorded
during the study period. Data are presented as n (%)

Table 1 Baseline characteristics of the 1400 children included Type and mechanism of medication errors n¼40
in the study. Values are presented as median [inter-quartile
range] or n (%) Type
Incorrect dose 27 (67.5)
Characteristics n¼1400 Omission 5 (12.5)
Substitution 4 (10)
Age (yr) 5 [1e11] Repetition 3 (7.5)
Body weight (kg) 25 [11e36] Insertion 1 (2.5)
ASA physical status Mechanism
1 1083 (77) Setting of syringe pump 8 (20)
2 264 (19) Inadequate communication 8 (20)
3 53 (4) Dose calculation with incorrect weight 5 (12.5)
Indication for general anaesthesia: Non-observance of institutional guidelines 4 (10)
Visceral, urological and thoracic surgery 506 (36) Mere oversight 4 (10)
Cephalic surgery 428 (31) Incorrect or no labelling 2 (5)
Orthopaedic surgery 344 (25) Miscalculation 2 (5)
Other procedures 122 (9) None declared 8 (20)
 Medication errors in paediatric anaesthesia - 567

Table 4 Preoperative and intraoperative characteristics of the patients experiencing (Medication errors group) or not (No medication
error group) a medication error during the anaesthetic procedure or in the recovery room. Data are presented as median [inter-quartile
range] or n (%). *Variables tested in multivariate analysis (P<0.2 in univariate analysis) zMissing data for nine patients. CI, confidence
interval

Characteristics Medication No medication Univariate odds P-value

errors (n¼37) error (n¼1363) ratio [95% CI]

Age (yr) 5 (1e10) 5 (1e11) 0.99 [0.9e1.1] 0.61

Body weight (kg) 18 (10e35) 18 (11e36) 0.99 [0.9e1] 0.31
ASA physical status
1 28 (76) 1055 (77) 0.9 [0.4e1.9] 0.80
2 6 (16.2) 258 (19) 1.2 [0.5e3.1] 0.68
3* 3 (5) 50 (3) 2.3 [0.7e7.8] 0.17
Indication for general anaesthesia:
Visceral, thoracic, and urological surgery 15 (41) 491 (36) 1.2 [0.6e2.4] 0.56
Orthopaedic surgery 10 (27) 334 (25) 1.1 [0.5e2.4] 0.72
Cephalic surgery 11 (29) 417 (31) 0.95 [0.5e2] 0.91
Other procedures 1 (3) 121 (9) 0.3 [0.1e2.1] 0.22
Regional anaesthesia combined 9 (24) 386 (28) 0.8 [0.4e1.7] 0.59
to general anaesthesia
Duration of procedure (min)* 153 (87e246) 91 (64e134) 1 [1.0e1.1] <0.0001
Emergency procedure 10 (27) 433 (32) 0.8 [0.4e1.7] 0.54
Time of the day
Day work 35 (94) 1335 (98) 0.4 [0.1e1.6] 0.18
Night work* 2 (5) 28 (2) 2.7 [0.6e12]
Number of people in chargez
2 11 (30) 378 (28) 1.1 [0.5e2.2] 0.81
3 26 (70) 976 (72) 0.9 [0.4e1.9]

cases with at least one medication error was >2%. Incorrect
dose was the most frequently reported error, mainly related to
inappropriate rate of infusion or inadequate communication
within the anaesthetic team. Duration of procedure >120 min
was the only independent risk factor associated with medi-
cation error.
The rate of medication errors was much higher than that
reported in similar studies performed in adult patients, which
ranged from 1/92 to 1/169 cases.4e7 This result is not surpris-
ing, as higher incidence of medication errors has been re-
ported in paediatric compared with adult inpatients.3,19
Nevertheless, a study performed in South African teaching
hospitals reported an error incidence of only 1/267 cases in the
subgroup of paediatric patients, which was lower than that
calculated in adult patients.5 More recently, a subgroup anal-
ysis performed by Cooper and colleagues4 reported an inci-
dence of medication errors of 1.7% in paediatric patients and
of 0.45% in adult patients. Our results further support that
Table 5 Multivariate regression analysis of the parameters
associated with the occurrence of at least one medication
error during the anaesthetic procedure or in the recovery
room in univariate analysis. Model calibration using the
HosmereLemeshow test for goodness of fit was good (P¼0.87).
CI, confidence interval
Variable Adjusted odds P-value
ratio (95% CI)
ASA physical 1.5 (0.4e5.2) 0.56
status 3
Duration of procedure 4.5 (2.2e9.1) 0.0001
>120 min
Anaesthesia performed 3.3 (0.7e15.5) 0.13
during the night
medication errors are not uncommon in the setting of paedi-
atric anaesthesia.
Incorrect dose represented two-thirds of medication errors.
Woo and colleagues19 previously reported that accidental
overdose was eight-fold higher in children than in adult pa-
tients. A number of studies confirm this finding, identifying
incorrect dose as the most frequent type of medication error in
paediatric inpatients and paediatric anaesthesia.2,4,11,20,21 This
might be related to the frequent need for weight-adjusted dose
for paediatric patients, especially as there was no protocol for
drug dilutions in our unit, leading to different dilutions pre-
pared for the same drug among the senior anaesthetists and
nurse anaesthetists, leading to confusion and misunder-
standing between preparer and administrator. Hence, in our
study, one-quarter of incorrect doses were related to problems
with drug dilution.
Substitution accounted for only 10% of medication errors in
our study. Llewellyn and colleagues5 reported that substitu-
tion was as frequent as incorrect dose in paediatric anaes-
thesia, which representing the main types of medication
errors in this setting. In both adults and children, Cooper and
colleagues4 found that substitution accounted for 25% of
medication errors. Substitution errors are mainly related to
ampoule misidentification and to lack of appropriate medi-
cation labelling.5,22 Inappropriate labelling was involved in
only 5% of medication errors in our study. These encouraging
results might be related both to improved labelling practices
since the publication of standards and guidelines in several
countries,13e15 and, in particular, to the harmonization of
labelling of injectable drugs vials by the French Health Prod-
ucts Agency combined with the first publication of French
guidelines for prevention of medication errors in anaesthesia
in 2007.16,23
Interruption was the most frequent contributing factor for
medication error, which is frequently pointed out as
 568 - Gariel et al.
significant contributor to medication errors.24 Other authors
identified distraction, haste, and misread label as the most
frequent factors, accounting for 40% of errors.4,6,7 Interest-
ingly, preparation and administration by two distinct practi-
tioners was perceived as a contributing factor for medication
error in ~20% of cases. It has been suggested that involving at
least two professionals in prescription, preparation, and drug
administration would improve checking and monitoring of the
process.25 This would require appropriate communication and
standardized practices among the practitioners. In our study,
inadequate communication and non-standardized drug dilu-
tion practice were each reported as involved in the medication
error in ~20% of the cases. Further studies are therefore
required to assess whether the number of professionals
involved in the anaesthetic case affects the risk of medication
error.
As previously reported,4,6 fatigue was reported as being a
factor for medication error in only a few cases. Both the lack of
objective assessment of fatigue and the low night activity in
our institution probably contributed to prevent reliable anal-
ysis for this factor. It can also be assumed that fatigue affected
the ability to detect medication errors that did not lead to
clinical consequence. Furthermore, fatigue might also have
reduced voluntary participation to the study.
Duration of procedure >120 min was the only independent
factor associated with medication errors in our cohort. In adult
patients, Nanji and colleagues8 recently reported that the rate
of medication errors and adverse drug events related to
anaesthesia significantly increased with duration of proced-
ure. This could in part be related to the number of drugs
administered that increases with duration of surgery. Unfor-
tunately, in the present study, the number of drugs adminis-
tered during each anaesthetic procedure was not recorded in
the forms, and no significant association was previously re-
ported between medication errors and number of drug ad-
ministrations in adult anaesthesia.8 Further studies are
therefore required to clarify the factors involved in the risk of
medication errors when duration of the procedure is
prolonged.
As previously reported,5,26 emergency surgery was not
associated with an increase in the rate of medication errors.
Kozer and colleagues27 previously suggested that stress and
emergency might both lead to lack of appropriate time to focus
on dose calculation in mock resuscitation, thus contributing to
a high risk for medication errors. However, in our unit,
‘emergency surgery’ mainly corresponded to unplanned sur-
gery and not to ‘life-threatening’ situations, and was therefore
probably not associated with heightened stress.
Weight, patient age, and increased ASA status were not
associated with increased risk for medication errors, although
previous studies reported that these factors were significantly
associated with medication errors in general paediatric ward
and emergency paediatric medicine.20,28 In our hospital, the
anaesthesia team was composed of anaesthetists and nurse
anaesthetists specialized and experienced in paediatric
anaesthesia, and used to caring for infants and preterm in-
fants. However, the number of patients with ASA status >2
was low in our cohort, and was probably insufficient to
determine statistical significance. Nevertheless, younger age
could be associated with increased risk for clinical conse-
quences related to medication errors, as dose errors are more
likely to lead to adverse events in low weight children.3 Three
patients with clinical events because of medication errors
were all <1 yr of age.
Many medication errors could be avoided through pre-
vention strategies,25,29 such as reducing the number of
different dilutions allowed for each drug according to a pro-
tocol.25 Preparation and administration of medications by the
same person, exhaustive labelling of medications using a
colour-coded labelling system and double checking before
administration can also minimize the risk and clinical con-
sequences of medication errors.9,25,30e32 Use of prefilled sy-
ringes can lead to significant cost savings when compared
with syringe preparation in the operating room, and can
contribute to fewer medication errors.33 The use of electronic
support could also be useful in order to avoid ampoule
swap.32,34,35 More generally, education related to medication
errors, drug preparation, and drug administration should be
reinforced among physicians and nurses anaesthetists, using
simulation to raise awareness of the importance of medication
error risk in paediatric anaesthesia. The effectiveness of such
preventive measures should be assessed in further studies in
the setting of paediatric anaesthesia. Some of the failures in
drug treatment might be related to violations rather than er-
rors, requiring complementary preventive strategies. In fact,
violation differs from error because it is deliberate while error
is unintentional.25,36 Hence, violations can be averted by
choice, provided that hospital organization contributes to high
adherence with protocols by making them accessible and
easy-to-apply, while ensuring appropriate working conditions,
avoiding excessive fatigue for professionals, and performing
continuous monitoring of medical practices.36
The present study has several limitations. This was a
single-institution study that was conducted in an exclusively
paediatric surgical centre. The results cannot be uniformly
transposed to all surgical centres, in particular to centres
where paediatric anaesthesia represents only a small propor-
tion of patients. Reliance on voluntary reporting might have
underestimated the true incidence of errors because of even-
tual recognized but non-declared errors, and because of po-
tential unrecognized errors. Thus, incident reports
underestimate the rate of medication errors when compared
with direct observation by experts.37 In paediatric wards, even
observation by parents seems to detect errors that were not
reported in medical records.38 A simulation study in a paedi-
atric emergency department showed that 16% of prepared
syringes did not contain the expected dose.27 Similar results
were found in our department.39 Such medication errors
would not be recognized by the anaesthetic team in charge of
the patient, unless they led to clinical consequences. The
method based on voluntary reporting is therefore not optimal
to assess the incidence of medication errors as previously
pointed out,8 but each method has its own limitations.40 For
example, external observers can affect professional behaviour
related to the Hawthorne effect, and syringe analysis detects
only preparation errors. Another limitation was that the drugs
administered during each anaesthetic procedure were not
recorded on the forms. This prevented analysis of whether one
medication or one class was associated with increased risk for
medication error. Opioids and antibiotics were the drugs most
involved in medications errors, probably because they are
used frequently during anaesthesia. Conversely, neuromus-
cular blocking agents are rarely administered in our unit and
were therefore not involved. Further studies are required to
assess if one particular medication class is at an increased risk
of error. Finally, we focused mainly on medication adminis-
tration errors, while medication errors also involve failures in
monitoring the effect of a drug and errors in recording

administration, both corresponding to insufficient care in
medication practice.8,25,32 Thus, Merry and colleagues32
demonstrated that reducing errors in the recording of drug
administration led to reduced medication errors in
anaesthesia.
In conclusion, medication errors are not uncommon in
paediatric anaesthesia, as at least one medication error
occurred per 38 general anaesthetic cases. These errors mainly
involved incorrect doses and dilution errors. The identification
of the mechanisms of medication errors might allow preven-
tive measures that could be assessed in further studies.
Authors’ contributions
Study design/planning: B.C., D.C.
Study conduct: B.C., C.G., F.-P.D.
Data analysis: F-P.D., L.B.
Writing paper: C.G., L.B., F.-P.D.
Revising paper: all authors.
Declaration of interest
None declared.
Acknowledgments
The authors thank all nurse and physician anaesthetists for
their participation in the study. The authors also thank Pro-
fessor Bernard Allaouchiche, MD, PhD, for his help in the
statistical analysis.
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Handling editor: H.C. Hemmings Jr