Evidence‐based strategies for preventing drug administration errors during anaesthesia

Jensen, L.D.; Merry, Alan; Webster, Craig; Weller, Jennifer; Larsson, Lars

doi:10.1111/j.1365-2044.2004.03670.x

Cited by 208 publications

(158 citation statements)

References 99 publications

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“…Our observation that anesthesia providersin-training tend to report these errors more often than experienced providers also suggests that more focused education in management and administration is desirable to minimize medication errors/pre-errors during the early part of specialty training. 25 In conclusion, reports of medication errors/pre-errors continue to occur in the practice of anesthesiology. Although our reporting incidence rates were similar to those of other studies, we also observed that surgical case type, patient ASA classification, and the level of provider experience play a role in the frequency of medication errors/pre-errors in a large academic teaching hospital.…”

Section: Resultsmentioning

confidence: 93%

Influences observed on incidence and reporting of medication errors in anesthesia

Cooper

DiGiovanni

Schultz

et al. 2012

Can J Anesth/J Can Anesth

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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.

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Section: Resultsmentioning

confidence: 93%

Influences observed on incidence and reporting of medication errors in anesthesia

Cooper

DiGiovanni

Schultz

et al. 2012

Can J Anesth/J Can Anesth

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show abstract

“…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. 8,13 In this review, we focus on systems designed to reduce medication errors in the operating room and highlight three Canadian initiatives: 1) systematic efforts to improve the labelling of drug ampoules and vials, 2) introduction of bar-coding in medication systems, and 3) novel tools for ''reconciliation'' or for accurate documentation and adjustment of patients' medication taken before and during their hospital stay.…”

Section: Résumémentioning

confidence: 99%

“…This article concludes with a description of emerging issues for drug safety in anesthesia. Readers interested in more comprehensive reviews of medication errors in anesthetic practice are referred to other articles 12,14 and recommendations. [14][15][16][17][18] Medication safety in anesthesia…”

Section: Résumémentioning

confidence: 99%

“…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. Here, we discuss systembased interventions to improve the labels on drug ampoules and to introduce bar-coding systems.…”

Section: Résumémentioning

confidence: 99%

See 1 more Smart Citation

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

Orser

Hyland²,

David³

et al. 2012

Can J Anesth/J Can Anesth

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Purpose This article presents a summary of recent advances, including tools and interventions, that are designed to improve drug safety for patients in critical care settings, particularly those undergoing anesthesia and surgery. Principal findings Medication error remains a leading cause of adverse events among patients undergoing anesthesia. Misidentification of ampoules, vials, and syringes is a common source of error. Systems are now being engineered to reduce the likelihood of medication misidentification through approaches such as revision of standards for labelling of drug ampoules and vials and the development of bar code systems that allow ''double checking'' or drug verification in the operating room. Also, efforts are being made to improve medication reconciliation, a process for accurately communicating a patient's medication information during transitions from one healthcare setting to another. Finally, the opportunity exists for anesthesiologists to increase awareness about the rising problem of opioid addiction in patients for whom typical doses are initially prescribed for appropriate indications such as postoperative pain. Conclusions There is a need to improve drug delivery systems in complex critical care environments, particularly the operating room. Anesthesiologists must continue to play a leading role in promoting drug safety in these environments.

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“…Our records also indicate that reports of inaccurate invasive pressure readings are extremely rare. Additionally, invasive methods typically show more consistency than non-invasive methods for reading arterial pressure [1].…”

Section: A Replymentioning

confidence: 99%

Anaesthesia after cleft palate repair

Dearlove¹,

Perkins²,

Briggs³

2004

Anaesthesia

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Evidence‐based strategies for preventing drug administration errors during anaesthesia

Cited by 208 publications

References 99 publications

Influences observed on incidence and reporting of medication errors in anesthesia

Influences observed on incidence and reporting of medication errors in anesthesia

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

Anaesthesia after cleft palate repair

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