Evaluation of Perioperative Medication Errors and Adverse Drug Events

Nanji, Karen C.; Patel, Amit; Shaikh, Sofia D.; Seger, Diane L.; Bates, David W.

doi:10.1097/01.sa.0000504595.97213.42

Cited by 13 publications

(48 citation statements)

References 14 publications

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“…Although medication error self-reporting has improved at our institution, reported error rates (1.56/ 1000 anesthetics) remain much lower than those reported with prospective observational data (84 errors/ 1000 anesthetics at our institution or 552 errors/1000 anesthetics at others) (6). Thus, it is likely that errors continue to be underreported.…”

Section: Limitationscontrasting

confidence: 42%

“…This often occurs without added safety mechanisms such as computer decision support, pharmacy review, or independent double checks, which are standard in other health care arenas. A recent prospective observational study by Nanji et al (6) reported a high rate of perioperative medications errors by anesthesiologists, one in every 20 medication administrations. Pediatric patients were excluded from their observations, a population which The Joint Commission estimates is at a three times higher risk for medication-related adverse events (7,8).…”

Section: Introductionmentioning

confidence: 99%

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Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Martin

Grigg

Verma

et al. 2017

Pediatric Anesthesia

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SummaryThe Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

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Section: Limitationscontrasting

confidence: 42%

Section: Introductionmentioning

confidence: 99%

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Martin

Grigg

Verma

et al. 2017

Pediatric Anesthesia

View full text Add to dashboard Cite

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“…Thus perioperative ADRs are usually underreported [20] . Therefore, it is important that drugs with a well-known safety profile are being used in this most crucial period [21] . Our study pointed out that the most common surgery related drugs that were used belonged to the classes of analgesics, antibiotics, antiemetics and gastroprotectants.…”

Section: Resultsmentioning

confidence: 99%

Patterns, Predictors and Outcomes of Polypharmacy among Elderly Perioperative Patients in the General Surgical Department of a Tertiary Care Teaching Hospital

Saldanha¹,

Raj²,

Devi³

et al. 2017

pharmaceutical-sciences

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“…Even after 15 years of patient safety initiatives, recent research has found that roughly one in two surgeries had a medication error and/or an adverse drug event (Nanji, Patel, Shaikh, Seger, & Bates, 2016) and more than 12 million patients each year experience a diagnostic error in outpatient care, half of which are estimated to have the potential to cause harm (Singh, Meyer, & Thomas, 2014). On the other side, there is 1.3 million estimated reduction in hospital-acquired conditions (2011)(2012)(2013) as a result of the federal Partnership for Patients initiative (Agency for Healthcare Research and Quality, 2015).…”

Section: Theoretical Backgroundmentioning

confidence: 99%

Analysis of Development in Patient Safety Over the Last 15 Years

Ehrnsperger¹

2016

UCPA

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Patient safety is a significant healthcare issue with substantial clinical and economic consequences. The extensive research in 1999 on patient safety stated that preventable medical errors in US were killing as many as 99,000 people per year. The aim of this paper is through the analysis of patient safety management development to identify main obstacles and success factors for its improvement, coming from global literature review combined with a case study. The literature review was a qualitative meta-analysis from which identified barriers and critical success factors for improvement. This research is underlined by a case study which also shows clear adoption barriers. In the result of analysis of literature review and secondary statistical data, main conclusions can be stated such as: (1) The scope of improving patient safety has not made significant progress and further efforts are rare and not centred;(2) Several macroeconomic obstacles are still observable end especially in the field of commitment, funding, and education, but main attention paid by author of this paper is the analysis of managerial aspects of patient safety at micro-level which is creating the third group of conclusions.

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Evaluation of Perioperative Medication Errors and Adverse Drug Events

Abstract: Background-The purpose of this study is to assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, evaluate their root causes, and formulate targeted solutions to prevent them.

Cited by 13 publications

References 14 publications

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Patterns, Predictors and Outcomes of Polypharmacy among Elderly Perioperative Patients in the General Surgical Department of a Tertiary Care Teaching Hospital

Analysis of Development in Patient Safety Over the Last 15 Years

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