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May 17, 2026THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA0 citationsOpen Access

Patient Safety in the Pediatric Operating Room:Extravasation and Medication Errors

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SNShinichi Nishibe

Key Points

  • The aim is to address high safety risks in pediatric operating rooms related to extravasation and medication errors.
  • Utilized color-flow injection test with ultrasound for early detection of extravasation.
  • Implemented an error prevention system focusing on syringe labeling, dosage verification, and selection accuracy.
  • High sensitivity and specificity observed for ultrasound in detecting extravasation.
  • Error prevention systems significantly reduced incidence of incorrect doses and medication swaps.

Abstract

小児麻酔を実践する手術室は,医療安全上のリスクの高いエリアである.点滴漏れと誤薬は頻度が高く,発生した場合には患児への影響が大きい.点滴漏れの早期発見が重症化を防ぐために重要であるが,自然滴下による確認では見逃す可能性があり,超音波診断装置を用いたColor-flow injection testの感度・特異度が高い.薬剤を投与する時には,量の間違い(incorrect dose)と薬剤の間違い(ampule/vial swapとsyringe swap)に注意が必要である.シリンジラベル印刷から,投与量の確認,シリンジ選択の誤りを軽減するための誤薬防止システムを導入し,活用している.

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Cite This Study

Shinichi Nishibe (2025) studied this question.

synapsesocial.com/papers/6a095a427880e6d24efe06d5https://doi.org/10.2199/jjsca.45.207
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