Medication Errors In Anesthesia Research Articles

Addressing anesthesia medication errors for improved quality care

Medication errors in anesthesia can have serious consequences for patients, including morbidity and mortality. These errors can occur at any stage of the medication administration process, from prescribing and preparation to administration and monitoring. Learning from medication errors is essential to improving patient safety in anesthesia. To address medication errors in anesthesia, various strategies have been developed, including the use of checklists, protocols, and simulation training. The implementation of technology, such as barcode scanning and automated dispensing systems, has also been effective in reducing medication errors. Learning from medication errors involves identifying the root causes of the error, analyzing the factors that contributed to the error, and implementing strategies to prevent similar errors from occurring in the future. A culture of safety that encourages reporting and analysis of errors is crucial for learning from medication errors. Improving patient safety in anesthesia requires a collaborative effort among healthcare professionals, including anesthesiologists, nurses, and pharmacists, as well as a commitment to continuous improvement through learning from errors.

Interventions to reduce medication errors in anesthesia: a systematic review.

The objective of this study was to provide a synthesis of the interventions designed to reduce medication errors in anesthetized patients. We electronically searched major databases using index and free-text keywords related to anesthesia and medication errors. We included cohort studies exploring interventions to reduce anesthetic medication errors in both adult and pediatric patients. The risk of bias for each study was assessed using the Newcastle-Ottawa Scale. One thousand five-hundred and fifty-eight titles or abstracts were screened, and 56 full-text studies were assessed for eligibility; eight studies were included in the final analysis. Case reports and retrospective studies were excluded. The quality of most studies (n = 6) was graded as "low". There were three categories of interventions: I) multimodal interventions (6 studies, n = 900,170 medication administrations) showed a reduction in rates of errors of 21-35% per administration and 37-41% per anesthetic; II) improved labels (1 study, n = 55,426 medication administrations) resulted in a 37% reduction in rates of errors per anesthetic; and III) the effect of education was assessed in one study and showed no effect. Multimodal interventions and improved labelling reduce medication errors in anesthetized patients.

Safe Labeling Practices to Minimize Medication Errors in Anesthesia: 5 Case Reports and Review of the Literature

Drug error is a significant hazard to patient health. Poor, incorrect, and inconsistent labeling of injectable medicines and fluids, and the devices used to deliver these, has been identified as a patient safety issue. We report 5 cases of medication error as a consequence of incorrect or inappropriate labeling and analyze their cause. Recommendations for safe and practical labeling practices in anesthesia based on a review of the literature are presented. Implementation of the recommended labeling practices can reduce the risk of medication error and contribute to the safe administration of drugs.

Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study.

Medication errors continue to be a significant source of patient harm in the operating room with few concrete countermeasures. The organization and identification of medication syringes may have an impact on the commission of medication errors in anesthesia, so a team of physicians and designers at the University of Washington created the Anesthesia Medication Template (AMT) to define a formal way of organizing the anesthesia workspace. The purpose of this study is to assess the ability of the AMT to reduce perioperative medication errors by anesthesia providers. This study evaluated the AMT in 2 phases: (1) 41 anesthesia providers administered medications in 2 prospective, randomized operating room simulations with or without the AMT, while medication errors were directly observed; and (2) around 200 providers prospectively self-reported medication errors from all anesthetizing locations during a 2-year period at Seattle Children's Hospital, an academic, pediatric medical center. In simulated emergencies, the odds of medication dosing errors using the AMT were 0.21 times the odds of medication dosing errors without AMT (95% confidence interval [CI], 0.07, 0.66), controlling for scenario, session, training level, and years at training level. During the year after implementation of the AMT, the mean monthly error rate for all reported medication errors that reached patients decreased from 1.24 (95% CI, 0.85-1.79) to 0.65 (95% CI, 0.39-1.09) errors per 1000 anesthetics. The mean monthly error rate of reported swap, preparation, miscalculation, and timing errors decreased from 0.97 (95% CI, 0.64-1.48) to 0.35 (95% CI, 0.17-0.70) errors per 1000 anesthetics. Medication errors that resulted in patient harm did not change after implementation of the AMT. Standardizing medication organization with the AMT is an intuitive, low-cost strategy with the potential to improve patient safety through reducing medication errors by anesthesia providers.

Research progress of medication error management in anesthesia

Medication error in anesthesia is a serious problem, which may endanger to patients′ life. The aim of this article is to review the study on medication errors in anaesthesia, so as to provide references for building the prevention strategies against medication errors in anaesthesia, and ensure the safety of patients. Key words: Review; Anesthesia; Medication error; Management

Simulator evaluation of a prototype device to reduce medication errors in anaesthesia

We undertook a randomised control led trial to evaluate the effect of a prototype device which attaches to the intravenous drug administration port, and allows injection of intravenous drugs only after the user scans the barcode on the syringe label. This requires two steps: first, that the correct drug label is generated; and second, that the syringe-with-label is scanned before administration. Ten anaesthetists, who were unaware of the primary outcome being measured, administered general anaesthesia for two simulated standardised cases each without and with our prototype (control and intervention, respectively). The primary outcome measured was compliance with a safe drug administration procedure (defined as a two-step procedure where, step one is scanning a drug ampoule to print a label for a syringe and step two is scanning of the labelled syringe before administering it intravenously). A total of 182 intravenous drug administrations occurred in the study (91 in each group). We found that the use of our prototype increased safe drug administration behaviour in experienced anaesthetists; 33 (36.3% [95% CI 26-47%]) vs. 91 (100% [95% CI 96-100%]) in the control and intervention groups, respectively (p = 0.0001).

In-simulo evaluation of a prototype device to reduce medication errors in anaesthesia: A proof-of-concept study

In-simulo evaluation of a prototype device to reduce medication errors in anaesthesia: A proof-of-concept study

Never trust a drug that can be pronounced in three different ways: medication errors in anaesthesia

Medication errors cause patient death or injury. The worst medication errors involve patient-adverse events with an unknown medication error. This leads to wrong factors being incorrectly blamed and to the development of an illogical adverse event preventive protocol. Most medication errors cause no patient harm. There is a higher risk of medication errors occurring in paediatric than in adult anaesthesia as more drugs need to be diluted. 1

Errores de medicación y etiquetado de las jeringas

Drug-related problems are frequent in the hospital setting and sometimes lead to patient harm and increased costs. The “Helsinki Declaration on Patient Safety in Anesthesiology” includes, among other recommendations, that all anesthesia departments have protocols for the correct labelling of syringes containing the medication required for anesthesia. In accordance with this document, the Spanish System of Safety Reporting in Anesthesia and Resuscitation and the Spanish Society of Anesthesiology and Resuscitation, together with the Institute for Safe Medication Practices in Spain have recently published their recommendations on the labelling of syringes, lines and bags. The present article briefly reviews medication errors in anesthesia and the role of medication labelling in patient safety.

Medication Errors in Anesthesia

Medication Errors in Anesthesia

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Introduction: Several factors contribute to medication errors in anesthesia. In 2010, the Anesthesia Patient Safety Foundation set forth a medication safety paradigm consisting of four elements – standardization, technology, culture, and pharmacy/pre-filled/pre-mixed. The purpose of this study is to assess the impact of incorporating standardization and ready-to-use (RTU) medications in the intraoperative setting. Hypothesis: Pharmacy provided RTU medications in standardized concentrations and locations will enhance the safety and quality of medications administered. Methods: A prospective before-and-after anesthesia medication safety study was conducted in an academic medical center consisting of 78 anesthetizing locations and 3 pharmacy satellites. Key performance metrics including labeling compliance, medication preparation details, and waste data were collected for the first surgical cases of the day. After collection of initial state data, anesthesia medication trays were standardized across 64 operating rooms and 14 remote areas. The trays incorporated RTU syringes of medications commonly used for anesthesia induction, reversal, and emergencies. Vasoactive drip concentrations and diluents were standardized across the institution. Pharmacy increased production of several compounded sterile products that were dispensed to anesthesia providers upon request. Six months after the intervention, post-implementation data was collected to assess impact and sustainment. Results: The medication management practices of 200 cases were observed. Inclusion of medication concentration on the label significantly increased from 31% pre-intervention to 78% post-intervention (p<0.001). Provider prepared syringes of medications were significantly reduced from 88.8% to 32.8%. (p<0.001) and provider prepared intravenous admixtures were reduced from 89% to 2.9% (p<0.001). RTU medications also reduced medication waste. The largest reduction was noted for emergency medications such as atropine (93.9% reduction), succinylcholine (93.5% reduction) and phenylephrine (96.3% reduction). Conclusions: Extending pharmacy services throughout the intraoperative setting resulted in a sustained improvement in anesthesia medication safety and quality.

Erratum to: Influences observed on incidence and reporting of medication errors in anesthesia

Erratum to: Influences observed on incidence and reporting of medication errors in anesthesia

Influences observées sur l’incidence et le signalement des erreurs médicamenteuses en anesthésie

Medication errors are a common occurrence during the conduct of anesthesia (one in 133-450 [corrected] patients). Several factors contribute to medication errors in anesthesia, including experience of the anesthesia provider, severity of comorbidities, and type of procedure. The inexperience of anesthesia providers-in-training also leads to increased error rates. This prospective observational study repeats and extends previous work by Webster et al. and Llewellyn et al. examining the role of comorbidities, type of case, and level of provider experience on the incidence of medication errors. After Institutional Review Board review and exemption from informed consent, medication error reporting forms were attached to every anesthetic record during a six-month period. All providers were asked to return the forms for every anesthetic, on a strictly voluntary and anonymous basis, and to record the occurrence of medication errors. If providers indicated that a medication error had occurred, additional details about the event were obtained anonymously. There were 8,777 (83%) responses obtained in a review of 10,574 case forms. A medication error was reported in 35 forms, with an additional 17 forms indicating a medication pre-error or near miss, resulting in 52 (0.49%) errors/pre-errors or a reported incidence of 1:203 anesthetics. Most case types were observed to have a statistically significant increase in reported medication errors. Reported errors by type of anesthesia provider were categorized into anesthesia provider-in-training group and the experienced provider group. The anesthesia provider-in-training group reported a twofold increase in the rate of errors, with the most frequently reported errors being incorrect dose and substitution. This study suggests that case type, American Society of Anesthesiologists' classification, and level of provider experience play a role on the rate of medication errors. The results of this study are in agreement with previously reported error rates.

198 Evaluate to prevent medication errors in anaesthesia

198 Evaluate to prevent medication errors in anaesthesia

Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital

The Japanese Society of Anesthesiologists (JSA) has investigated critical events in several fields of anesthesiology. However, the types, frequency, and characteristics of medication errors related to anesthesia have not been investigated. By analyzing incident reports retrospectively, we investigated medication errors that occurred during anesthetic practice over the past 8 years at our institution. Incident reports related to medication errors that occurred between May 1999 and March 2007 were analyzed retrospectively using a questionnaire published by the JSA in the "Survey of medication errors related to anesthesia". During these 8 years, 233 incidents were reported, in a total of 27454 anesthesia cases conducted during this period. Of these incidents, 61 (26.2%) were anesthetic drug administration errors. In these 61 incidents, clerical error (e.g., erroneous prescription writing), and pre-error (defined as any incident with the potential to become an error) were excluded from the analysis. Consequently, 13 incidents were excluded and 48 incidents were analyzed. Medication errors due to overdose were the most frequent kind of error (25%), followed by substitution (23%), and omission (21%). Errors due to an incorrect route of administration were rare. The drugs most frequently involved in these errors were antibiotics and muscle relaxants. Most of the patients involved in the incidents were, fortunately, not harmed seriously. The total frequency of medication errors in the survey period was 0.175% (48 incidents in 27 454 total anesthesia cases). We found that overdose, substitution, and omission were the main causes of anesthesia-related medication errors in our department.

Medication errors in anaesthesia and critical care

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.