Influences observed on incidence and reporting of medication errors in anesthesia

Abstract

Background Medication errors are a common occurrence during the conduct of anesthesia (one in 113-450 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. Methods 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. Results 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 providerin-training group reported a twofold increase in the rate of errors, with the most frequently reported errors being incorrect dose and substitution.

Review article: Improving drug safety for patients undergoing anesthesia and surgery

“…6 The focus of this current review is on strategies that are currently being engineered into care delivery systems to reduce drug-related errors in anesthetic practice. Such errors, which occur at a rate of about 1 per 130-450 patients, [7][8][9][10][11] are associated with increases in morbidity, mortality, and the costs of hospital care. [8][9][10][11][12] Fortunately, most anesthetic-related errors are inconsequential; however, some lead to substantial or permanent injury and even death.…”

“…Based on a limited number of prospective studies, the estimated incidence of medication error in anesthetic practice ranges from 0.33-0.73%, 7,9 and the rate has not changed substantially in over 15 years. 11 Despite a growing awareness of the importance of drug safety, medication error is a major cause of medical malpractice for anesthesiologists in Canada.…”

“…The level of experience of the anesthesia care providers is another major contributing factor, given that the error rate is almost twice as high among trainees as among experienced anesthesiologists. 7,11 Evidence-based recommendations intended to minimize errors have been developed on the basis of a systematic review. 12 The most important recommendation is the implementation of system-based interventions to reduce drug errors during anesthesia.…”

Review article: The evolving role of information technology in perioperative patient safety

“…18 Five reports from around the globe over the next 11 years reported similar results. [19][20][21][22][23] These large-scale studies, some retrospective and others prospective, relied on paperbased technology. While these paper-based systems did show opportunities for improvement, the resources involved with reviewing paper records and incident reports have taken over 30 years to establish a baseline from which to assess the effect of intervention strategies on the rate of medication errors in anesthesia.…”

“…15 Cooper et al suggested that a shift of organizational culture over the past decade that emphasizes safety rather than blame may have accounted for the increased rate of voluntary reporting of errors that were observed over previously published reports. 23 The establishment of non-threatening environments may encourage clinician ''buy-in'' to clinical solutions aimed at improving patient care. Buntin et al found that the ''human element'' is critical to health IT implementation.…”