MEDICATION CRITICAL INCIDENTS REPORTED BY SENSAR (SPANISH CRITICAL INCIDENT REPORTING SYSTEM) FROM 2009 TO 2016. 
BACKGROUND: 
Medication related critical incidents are frequent. Most of them can be prevented. The impact of a medication incident can cause no harm or can be potentially dangerous and even lead to the patient’s death. 
The frecuency and potentially harm of the reported incidents lead us to remember the importance of enhancing efforts to protect patient’s. 
The goal of this study was to review the critical incidents reported by SENSAR related to medication errors. SENSAR is a Spanish national critical incident reporting system in Anesthesia. 
MATERIAL AND METHODS: 
We designed a prospective observational study in which we analyzed the medication related critical incidents reported by SENSAR during the period of time between January 2009 and October 2016. We used “medical errors” as key Word. We studied the contributing factors analyzers found to be related to the incidents, and the measurements locally proposed. 
RESULTS: 
Our review has a total amount of 6205 critical incidents reported, 1311 of them of medication. 
In terms of morbidity and mortality, the impact of these errors was variable, 61% did not cause any damage in the patient, 3% caused  no harm but  ended  up  with surgery suspension, 20% caused minor morbidity, 10% intermediate morbidity , 1% higher morbidity, and it is important to highlight that 0.3% of incidents  led to the death of the patient.
Most of the incidents are related with drug administration (16%), followed by prescription incidents (13%), storage of medication incidents (10 %) and drug dose incidents (9%).
Discussion: 
Incidents are notified and analyzed by local teams, and local improvement measures are implemented: the acquisition of a system of labeling, alerts to remember the need of double checking the medication before the preparation and administration, and the electronic prescription. Also, it is important to have the medication properly placed in the operating room, as well as the communication, presentation in session and the update and use of protocols. 
The multi-hospital system allows sharing effective measurements that can be useful for different institutions. In line with other publications locally applicable measures are the most frequent proposals.

Medication critical incicents reported by SENSAR (Spanish critical incident reporting system) from 2009 to 2016