Prevalence and Prevention of Medication Errors in Obstetric Anesthesia Practice

Dear Editor, We read with great interest the recent narrative review by Pruthi et al.[1] about medication errors in the obstetric anesthesia practice. The authors highlight multiple approaches to preventing medication errors, primarily on systemic strategies. However, the actual occurrence of medication errors during obstetric anesthesia or analgesia remains to be discovered because of the deficiency of in-depth medication error studies. In Figure 2, the authors illustrate a downward trend in medication incident rates in obstetric anesthesia from 2009 to 2021.[1] However, we could not locate a reference for the data they presented. We are curious about the source of their data as it is crucial for establishing the credibility of the incident rates depicted in Figure 2. In the section titled “Incidence and prevalence of drug errors in obstetric anesthesia,” it is noteworthy that most references are not specific to obstetric anesthesia. Therefore, as mentioned earlier, the evidence does not support the author’s assertion that drug errors in obstetric anesthesia are rare. Contrary to the authors’ view, the obstetric patient population may be more susceptible to medication errors. Obstetric interventions are often time-pressured, performed during non-routine hours, and are frequently associated with interruptions and distractions (e.g. during cesarean birth).[2] Data from the seventh National Audit Project (NAP7) of the Royal College of Anaesthetists, UK, highlight that obstetric anesthesia activity (cesarean section and labor analgesia) in evenings (6 pm–11.59 pm) and nights (12 am–7.59 am) contribute to 31% and 55% of all anesthetic activity in hospitals, respectively.[3] This heightened risk underscores the need for increased vigilance and caution in obstetric anesthesia practice. Medication errors listed and their route of administration [Figure 3a-c] appear incomplete and are difficult to visualize.[1] The data suggest that almost all drug errors in obstetric anesthesia occur via the neuraxial (intrathecal and epidural) route (35 neuraxial route errors vs. four via other routes as per Figure 3a-c). The author’s literature search for their data in Figure 3 is more cursory than comprehensive. Some recently published reviews that included clinical features, consequences, and application of human factor analysis and classification system for neuraxial route errors involving tranexamic acid (TXA), cardiovascular drugs, neuromuscular blocking drugs, potassium chloride, and magnesium sulfate demonstrate obstetric patients are at higher risk of drug errors as regional anesthesia is a standard of care.[4–6] During obstetric clinical care providers should specifically carefully handle TXA, digoxin, magnesium sulfate, local anesthetics, oxytocin, and antibiotics due to the potential for adverse outcomes.[4–6] We want to emphasize that not only neuraxial and parental routes (e.g. IV, IM) but also oral route errors may happen in rare circumstances.[7] Numerous evident and latent underlying factors in clinical practice (e.g., organizational, environmental, technological, and personal), make it particularly challenging to prevent medication errors in operating rooms. Specifically, in some countries, the structure and functionality of operating rooms may vary widely. Trained personnel (e.g. anesthesia assistants, midwives), high-tech facilities (e.g. automated dispensing cabinets for medication storage, barcode scanners, smart infusion pumps, prefilled syringes) and tools to report and monitor drug errors (e.g. incident reporting system, mechanisms to disseminate drug error alerts) may not be available in low-resource settings. We concur with the authors that more research on medication errors in obstetric patients may identify causes and contributory factors and that advanced technology can help mitigate medication errors. However, implementing advanced technology should include the importance of basic safety measures. Attention to detail, safe storage, reading of labels, double-checking (with other humans or barcode scanners), clear and legible labeling of syringes, infusion catheters, pumps, NRFit connectors for neuraxial devices, meticulous handover of care, situational awareness, and awareness and reporting of errors by all stakeholders are essential measures to minimize medication errors in obstetric wards and surgical environments. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.