The evolution of methods to estimate the rate of medication error in anaesthesia

Webster, Craig

doi:10.1016/j.bja.2021.06.008

Cited by 5 publications

(5 citation statements)

References 20 publications

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“…While self-reported medication error rates in the literature are generally very low, facilitated self-reporting captures more errors than voluntary self-reporting. [40] Direct observational studies of MEs capture even more MEs than both prospective and retrospective self-reported studies. [40] For example, Merry et al identified a 9.1% ME rate [33] and Nanji et al identified a 5.3% ME rate using direct observation methods.…”

Section: Discussionmentioning

confidence: 99%

“…[40] Direct observational studies of MEs capture even more MEs than both prospective and retrospective self-reported studies. [40] For example, Merry et al identified a 9.1% ME rate [33] and Nanji et al identified a 5.3% ME rate using direct observation methods. [1] Our results are also consistent with prior studies comparing methods for ME detection in non-perioperative settings.…”

Section: Discussionmentioning

confidence: 99%

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Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events

et al. 2022

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The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study [1] to those identified by self-report via a facilitated incident reporting system at the same 1046bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events

et al. 2022

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“…MEs are considered to be a worldwide health problem and have been reported in many countries around the world. 1,[19][20][21][22][23] However, the different backgrounds of the socioeconomic or health care systems among various continents or countries might affect the occurrence or pattern of MEs that occur.…”

Section: Discussionmentioning

confidence: 99%

“…We found that a dose error was quite common, this finding was consistent with the other studies’ finding. 1 , 7 , 23 Almost all of our patients had category D to I MEs; therefore, almost all of them had to be monitored in hospitals longer than the time required for management of the primary disease that caused their hospitalization. These MEs also increased hospital expenses and resulted in fewer unoccupied beds for other patients.…”

Section: Discussionmentioning

confidence: 99%

Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study

Tansuwannarat¹,

Vichiensanth²,

Sivarak³

et al. 2022

TCRM

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This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting. Patients and Methods: We performed a 10-year retrospective study (January 2011-December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome. Results: In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour-14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs. Conclusion: Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.

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“…Incident reporting is well established in healthcare, but better use of such incident data could be made in terms of identifying error-prone aspects of work systems where redesign efforts should be targeted ( 34 ). Such remedial approaches could then be tested and practiced during simulation before being phased into clinical practice.…”

Section: Discussionmentioning

confidence: 99%

The evolution of methods to estimate the rate of medication error in anaesthesia

Cited by 5 publications

References 20 publications

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events

Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study

Existing Knowledge of Medication Error Must Be Better Translated Into Improved Patient Safety

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