Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system

Abstract

Background: Medication-related adverse events (MRE) in anaesthesia care are frequent and require a deeper understanding if we are to prevent medication harm. Methods: We searched for reported MRE from the Spanish Anaesthesia Incident Reporting System (SENSAR) database over a 10-yr period. SENSAR is a cross-national, multicentre system focused on perioperative and critical care. A descriptive analysis of independent variables, phase of medication process, type of MRE, and medication group involved, and their relationships with morbidity was conducted. Results: A total of 1970 MRE were identified from 7072 reported incidents. Patient harm was reported in 31% of the MRE. The administration phase was more frequent (42%) and showed the highest harm rate (44%) compared with other medication process phases. The most frequent types of MRE were wrong treatment regimen and wrong medication (55% of cases). The medication groups most commonly reported were those that alter haemostasis (18%), vasoconstrictor agents (13%), and opioids (10%). Vasoconstrictor agents, benzodiazepines, and neuromuscular blocking agents were the medication groups involved in patient harm four-fold more, and opioids three-fold more, than medications that alter haemostasis. The 1970 incidents were investigated and led to implementation of 4223 local corrective patient safety and quality improvement measures. Conclusions: Patient harm in the perioperative setting from medications remains a major issue for patients, hospital leaders, and clinicians. We found patterns and specific causes that can be mitigated through proven systems solutions, and should be taken into consideration in designing sustainable solutions for safe perioperative care. Clinical trial registration: NCT03615898.

Peri-Operative Medication Errors in a Tertiary Care Teaching Hospital of a Low-Middle Income Country

“…Lobaugh et al reported an incidence of administration errors (65%) close to our ndings but studied it in pediatric cases [10]. In contrast Sanduende et al documented 42% errors during this phase 11 . Use of pre lled syringe has decreased preparation errors in some places 12 .…”

Anaesthesia drugs preparation and administration in Libyan tertiary hospitals: a multicentre qualitative observational study

“…9 A recent observational study on medication errors in the last 10 years, 10 observed 1 970 medication-related adverse events from 7 072 reported incidents with 31% of these incidents linked to patient harm. 10 The highest rate was reported during the administration stage in comparison to other medications process stages. Furthermore, various studies have shown risk of high error rates during preparation of intravenous medications.…”

Understanding the limitations of incident reporting in medication errors

“…These have attempted to collate the frequency, range, types, causes, and outcomes with the aim of 'finding and fixing' the sources of clinical mishaps. The study by Sanduende-Otero and colleagues 1 is unusual in reporting a range of events outside the USA and UK, and the corrective actions that were taken as a consequence. However, prior analysis and critique of these types of data still stand.…”

“…EditordWe read with interest the recent study published in the British Journal of Anaesthesia reporting an analysis of 1970 medication-related adverse events in anaesthesia over a 10-yr period. 1 A range of similar studies have been published over the last 20 yr that have explored a vast number of harms and near misses across multiple clinical contexts. These have attempted to collate the frequency, range, types, causes, and outcomes with the aim of 'finding and fixing' the sources of clinical mishaps.…”