Key result
Over a 15-year period, 311 peri-operative medication errors were reported, with 60% occurring during administration and 28% resulting in significant, serious, or life-threatening adverse events.
Observational (n=311)
No
Peri-operative medication errors frequently occur during the administration phase and are often due to human error, highlighting the need for low-cost systemic interventions like color-coded labels and high-alert warnings to improve patient safety.
Medication errors cluster in administration from human factors; supports low-cost safety bundles in LMIC settings while leaving open prospective outcome trials.
BackgroundIdentifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and various steps prior to drug administration. Our objective was to analyze the medication errors 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.MethodsAll Critical incidents (CI) reported during January 2004 till December 2018 were retrieved from CIRS database. Medication errors were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, 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.Results 311 medication errors were reported. Fifty two percent errors occurred in ASA II and III patient, and 43% during induction. Sixty % occurred during administration phase and 65 % were due to human error. Thirty seven percent were ADE, 58 of which were significant, 23 serious and five life-threatening errors. Majority errors involved neuromuscular blockers (32%) and opioids (13%).Conclusion 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. Twenty eight percent resulted in significant, serious, or life-threatening events.
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Abbasi et al. (2021) conducted an observational in Peri-operative medication errors (n=311). Peri-operative medication errors was evaluated on Frequency, characteristics, and severity of peri-operative medication errors. Over a 15-year period, 311 peri-operative medication errors were reported, with 60% occurring during administration and 28% resulting in significant, serious, or life-threatening adverse events.
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