Medication Errors in the Perioperative Setting

Abstract

Millions of patients undergo surgery each year, and receive a multiplicity of medications throughout the perioperative continuum. Medication errors are common, including errors in reconciliation from home to hospital, errors during anesthesia, errors at each of the possible transfers of care, and errors at discharge. A recent observational study puts the risk in the operating room at 1 in 20 medication administrations. Wrong patient, wrong drug (syringe or vial swaps), wrong time, wrong route, omissions, and repetitions are all common types of errors both reported and observed. Few interventions have been rigorously tested for their ability to decrease error rate, but expert opinions (literature review and consensus statements) focus on better use of technology (bar-coded syringes as well as bar code readers), increased pharmacy presence in all areas of perioperative medicine, increased use of prefilled, premixed syringes and infusions, and a culture of accountability and safety.