Medication errors in anesthesia: unacceptable or unavoidable?

Abstract

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Clinical utility of a targeted smartphone application to aid veterinary students in calculating constant rate infusions and perioperative fluid drip rates

“…Medical dosing errors may occur during the perioperative period resulting in unintentional, but preventable, morbidity and mortality 7–9 15. In human medicine, the estimated incidence of peri-anaesthetic period medication errors is between 0.33 per cent and 0.73 per cent per case 3 16 17. University veterinary teaching hospitals have reported a higher incidence of medication errors of up to 1.2 per cent 10 18.…”

Attitudes and Behaviors of Anesthesia Workers in Turkey Towards Drug Labeling: A Questionnaire Study

“…The most common causes of perioperative DAE include injection of the incorrect drug, administration of an excessive dose, incorrect route of administration and negligence. Inadequate follow-up of treatment or side effects, inadequate standardization of labels and protocols, carelessness, excessive workload, inappropriate working hours, poor communication, impetuousness, fatigue, medical and paramedical staff-related problems were also reported to contribute to DAE (4,8,14,(17)(18)(19)(20)(21)(22)(23)(24). In addition, incorrect or missing drug labels, interchange of syringe labels and vials, unlabeled syringes, and failure to estimate the dose of the drug were also reported (5,7,8,12,22).…”

Physicians' and Nurses' Attitudes and Actions Regarding Perioperative Medication Management

“…This raises the question as to whether the cognitive processes to ensure compliance with the five "rights" for the nurses have become an almost ritual act, without awareness of the task of administering medicine (5,7,26). Nurses are expected to prevent medication errors by combining the five safety checks with their knowledge about when a particular drug, dose, drug form or route of administration is not in the patient's best interest (22,24).…”

“…The perioperative period is considered to present the most risk, with an estimated 7.2% adverse drug events (ADEs) compared to 1.4% in general (5). Antibiotics and opioids top the list of drugs associated with serious, preventable ADEs, but these drugs are also important in the perioperative period (1,6,7). This raises concerns about the impact of human errors and possible weaknesses in the perioperative medication process (1,5), which can be fragmented due to challenges in collaborative professional relationships, clarification of responsibilities and communication, and differing documentation systems (4,(8)(9)(10)(11).…”

“…This raises concerns about the impact of human errors and possible weaknesses in the perioperative medication process (1,5), which can be fragmented due to challenges in collaborative professional relationships, clarification of responsibilities and communication, and differing documentation systems (4,(8)(9)(10)(11). Both latent errors (related to organizational and system factors) and active errors (e.g., lack of medication, incorrect dose or medication, rule violations) occur in the perioperative period (1,7,10,(12)(13)(14)(15)(16).…”