scholarly journals A Qualitative Exploration of Consultant Anaesthetists Attitudes to, and Experiences of, Perioperative Medication Errors in Emergency and Elective Theatre Settings

2021 ◽  
Vol 5 (1) ◽  
Author(s):  
Wilson-Baig N ◽  
Isba R

This case focuses on medication errors and adverse drug events occurring during the perioperative period by asking the question: What are the rates, types, severity, and preventability of medication errors (MEs) and adverse drug events (ADEs) in the perioperative setting during anesthesia care? This prospective observational study reported that approximately 1 in 20 perioperative medication administrations, and every second operation, resulted in an ME and/or an ADE. These rates are markedly higher than those reported by prior retrospective surveys. Process- and technology-based solutions may address the root causes of MEs to reduce their incidence.


2016 ◽  
Vol 124 (1) ◽  
pp. 25-34 ◽  
Author(s):  
Karen C. Nanji ◽  
Amit Patel ◽  
Sofia Shaikh ◽  
Diane L. Seger ◽  
David W. Bates

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, to evaluate their root causes, and to formulate targeted solutions to prevent them. Methods In this prospective observational study, anesthesia-trained study staff (anesthesiologists/nurse anesthetists) observed randomly selected operations at a 1,046-bed tertiary care academic medical center to identify MEs and ADEs over 8 months. Retrospective chart abstraction was performed to flag events that were missed by observation. All events subsequently underwent review by two independent reviewers. Primary outcomes were the incidence of MEs and ADEs. Results A total of 277 operations were observed with 3,671 medication administrations of which 193 (5.3%; 95% CI, 4.5 to 6.0) involved a ME and/or ADE. Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable. The events included 153 (79.3%) errors and 91 (47.2%) ADEs. Although 32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed ADE and an additional 70 (45.8%) had the potential for patient harm. Of the 153 errors, 99 (64.7%) were serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening. Conclusions One in 20 perioperative medication administrations included an ME and/or ADE. More than one third of the MEs led to observed ADEs, and the remaining two thirds had the potential for harm. These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative MEs.


2021 ◽  
Vol 12 (2) ◽  
pp. 136-142
Author(s):  
Sibghatullah M Khan ◽  
Shilpi Agarwal ◽  
Gaurav Agarwal ◽  
Jyoti Ghangas

2010 ◽  
Vol 120 (6) ◽  
pp. 1214-1219 ◽  
Author(s):  
Rebecca Rosenwasser ◽  
Almut G. Winterstein ◽  
Amy F. Rosenberg ◽  
Eric I. Rosenberg ◽  
Patrick J. Antonelli

2016 ◽  
Vol 125 (2) ◽  
pp. 429-431 ◽  
Author(s):  
T. Andrew Bowdle ◽  
Srdjan Jelacic ◽  
Bala Nair

Author(s):  
Blas Catalani ◽  
Steven Boggs ◽  
Ezekiel Tayler

2016 ◽  
Vol 124 (1) ◽  
pp. 1-3 ◽  
Author(s):  
Beverley A. Orser ◽  
David U ◽  
Michael R. Cohen

AORN Journal ◽  
2006 ◽  
Vol 83 (2) ◽  
pp. 351-368 ◽  
Author(s):  
BradLee Goeckner ◽  
Michael Gladu ◽  
Janet Bradley ◽  
Sandra C. Garmon Bibb ◽  
Rodney W. Hicks

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