Key result
Peri-operative medication errors occurred most frequently during the administration phase (60%), were primarily due to human error (65%), and resulted in adverse drug events in 28% of cases.
Why the study?
Identifying medication errors is one method of improving patient safety, particularly given the polypharmacy and complex steps in perioperative anesthetic management.
Cross-Sectional (n=311)
No
Peri-operative medication errors most frequently occur during the administration phase and involve neuromuscular blockers and opioids, highlighting the need for standardized labeling and protocols to reduce adverse drug events.
May merit targeted safety review in perioperative administration; hypothesis-generating and should not yet change practice.
Identifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and the steps followed prior to drug administration. Our objective was to identify, extract and analyze the medication errors (MEs) reported in our critical incident reporting system (CIRS) database over the last 15 years (2004-2018) and to review measures taken for improvement based on the reported errors. CIRS reported from 2004 to 2018 were identified, extracted, and analyzed using descriptive statistics and presented as frequencies and percentages. MEs were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, American Society of Anesthesiologist (ASA) status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement. Total MEs reported were 311, medication errors were reported, 163 (52%) errors occurred in ASA II and 90 (29%) ASA III patient, and 133 (43%) during induction. During administration phase 60% MEs occurred and 65% were due to human error. ADEs were found in 86 (28%) reports, 58 of which were significant, 23 serious and five life-threatening errors. The majority of errors involved neuromuscular blockers (32%) and opioids (13%). Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents. Medication errors were more frequent during administration. ADEs were occurred in 28% MEs.
No takes yet. Share an insight, caveat, or question.
Abbasi et al. (2022) conducted a cross-sectional in Peri-operative medication errors (n=311). Peri-operative medication handling was evaluated on Frequency and characteristics of medication errors. Peri-operative medication errors occurred most frequently during the administration phase (60%), were primarily due to human error (65%), and resulted in adverse drug events in 28% of cases.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: