Medical errors, including medication mistakes, kill more than 250,000 people every year.1
Medical errors are the 3rd leading cause of death in the U.S., behind heart disease and cancer.
Medication mistakes are the most common medical error. They cause 1.3 million injuries every year.3
Evaluation of Perioperative Medication Errors and Adverse Drug Events
Karen C. Nanji, M.D., M.P.H. et. al., appeared in Anesthesiology 2016; 124:25-34
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.
APSF Hosts Medication Safety Conference
John H. Eichhorn, MD, appeared in APSF Newsletter Spring 2010, Volume 25, No. 1, 1-20
On January 26, 2010, the Anesthesia Patient Safety Foundation (APSF) convened a consensus conference of 100 stakeholders from many different backgrounds to develop new strategies for “predictable prompt improvement” of medication safety in the operating room. The proposed new paradigm to reduce medication errors causing harm to patients in the operating room is based on Standardization, Technology, Pharmacy/Prefilled/Premixed, and Culture (STPC). This new paradigm goes far beyond the important but traditional emphasis on medication label format and the admonition to “always read the label.” Small group sessions on each of the 4 elements of the new paradigm (STPC) debated and formulated specific recommendations that were organized and prioritized by all the attendees.
Sweeping it Under the Rug: Why Medication Safety Efforts Have Failed to Improve Care and Reduce Patient Harm
Lebron Cooper & Paul Barach , appeared in the ASA Monitor in May 2018
“Read the label, read the label, read the label!”
Anyone who has administered anesthesia has probably heard or said this phrase many times in their career. And nobody wants to cause harm. How effective is repeating this in preventing medication errors and harm from anesthesia?
Anesthesia Medication Handling Needs a New Vision
Eliot B. Grigg and Alex Roesler, appeared in Anesthesia & Analgesia
Medication safety in the operating room: literature and expert-based recommendations
J. A. Wahr et. al., appeared in the British Journal of Anaesthesia, 118 (1): 32–43 (2017)
Human error poses significant risk for hospitalized patients causing an estimated 100,000 to 400,000 deaths in the USA annually. Medication errors contribute, with error occurring in 5.3% of medication administrations during surgery. In this study 70.3% of medication errors were deemed preventable. Given the paucity of randomized controlled studies, we undertook a rigorous review of the literature to identify recommendations supported by expert opinions.
Factors Contributing to Perioperative Medication Errors: A Systematic Literature Review
Julie Boytim and Beth Ulrich, appeared in the AORN Journal January 2018
We conducted a systematic literature review using PubMed and Ovid to analyze the factors contributing to perioperative medication errors (MEs). After the screening process, we included 19 studies in the systematic review. Certain factors emerged as contributors to perioperative MEs in the following categories: types of errors, causes of errors, human factors, medication types, and environmental factors. Across the studies, the most common type of error was wrong dose, and the most common causes of error were labeling and syringe swaps. Haste, stress, distraction, and decreased vigilance all increased MEs. Inaccurate medication reconciliation and patient lack of understanding contributed to MEs both preoperatively and postoperatively. Analgesics, antibiotics, and vasopressors were the medications associated with the highest incidences of error across the perioperative area. These findings may help clinicians formulate strategies to improve perioperative medication systems and decrease perioperative MEs.
Reduced opportunities for error may lead to fewer complications and shorter stays
An easy to implement tool that may improve safety and enacts significant portions of expert recommendations for anesthesia safety
A secure tray that enables easy and accurate reconciliation may improve charge capture and reduce drug waste via expiry and diversion.