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BMJ Open. 2019 Nov 25;9(11):e032686. doi: 10.1136/bmjopen-2019-032686.

Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis.

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Department of Surgery and Cancer, Division of Surgery, Imperial College London, London, London, UK
NIHR-Imperial Patient Safety Translational Research Centre, Imperial College London, London, London, UK.
Helix Centre for Design in Healthcare, Imperial College London, London, UK.
Centre for Mathematics of Precision Healthcare, Imperial College London, London, London, UK.
Department of Surgery and Cancer, Division of Surgery, Imperial College London, London, London, UK.
School of Pharmacy, University College London, London, London, UK.
Department of Paediatric Intensive Care, Division of Women and Children's Services, Imperial College Healthcare NHS Trust, London, London, UK.
Department of Emergency Medicine, Division of Medicine, Imperial College London, London, London, UK.



Medication errors during paediatric resuscitation are thought to be common. However, there is little evidence about the individual process steps that contribute to such medication errors in this context.


To describe the incidence, nature and severity of medication errors in simulated paediatric resuscitations, and to employ human reliability analysis to understand the contribution of discrepancies in individual process steps to the occurrence of these errors.


We conducted a prospective observational study of simulated resuscitations subjected to video microanalysis, identification of medication errors, severity assessment and human reliability analysis in a large English teaching hospital. Fifteen resuscitation teams of two doctors and two nurses each conducted one of two simulated paediatric resuscitation scenarios.


At least one medication error was observed in every simulated case, and a large magnitude (>25% discrepant) or clinically significant error in 11 of 15 cases. Medication errors were observed in 29% of 180 simulated medication administrations, 40% of which considered to be moderate or severe. These errors were the result of 884 observed discrepancies at a number of steps in the drug ordering, preparation and administration stages of medication use, 8% of which made a major contribution to a resultant medication error. Most errors were introduced by discrepancies during drug preparation and administration.


Medication errors were common with a considerable proportion likely to result in patient harm. There is an urgent need to optimise existing systems and to commission research into new approaches to increase the reliability of human interactions during administration of medication in the paediatric emergency setting.


paediatric A&E and ambulatory care; paediatric anaesthesia; paediatrics

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Conflict of interest statement

Competing interests: The Helix Centre at Imperial College London is leading an effort in collaboration with the British National Formulary developing digital tools in an attempt to improve paediatric medication safety. NA has written two patents describing syringe labelling techniques in medication safety. BF supervises a PhD student part funded by a supplier of hospital electronic health record systems and has received funding from Pfizer for organising and chairing two symposia on medication safety. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing we confirm that we have followed the regulations of our institution concerning intellectual property.

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