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Observational Study
. 2016 Jan;124(1):25-34.
doi: 10.1097/ALN.0000000000000904.

Evaluation of Perioperative Medication Errors and Adverse Drug Events

Karen C Nanji  1 , Amit Patel, Sofia Shaikh, Diane L Seger, David W Bates
Affiliations
Observational Study

Evaluation of Perioperative Medication Errors and Adverse Drug Events

Karen C Nanji et al. Anesthesiology. 2016 Jan.

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.

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Figures

Figure 1
Figure 1
The 193 events detected included 153 (79.3%) medication errors (MEs) and 91 (47.2%) adverse drug events (ADEs). A single event can involve both an error and an ADE. Of these events, 40 (20.7%) were ADEs that did not involve a ME, 51 (26.4%) were MEs that led to an observed ADE, 70 (36.3%) were MEs with the potential for an ADE (four intercepted and 66 non-intercepted), and 32 (16.6%) were MEs with little potential for harm.
See this image and copyright information in PMC

Comment in

  • Perioperative Medication Errors: Building Safer Systems.
    Orser BA, U D, Cohen MR. Orser BA, et al. Anesthesiology. 2016 Jan;124(1):1-3. doi: 10.1097/ALN.0000000000000905. Anesthesiology. 2016. PMID: 26501388 No abstract available.
  • Evaluation of Perioperative Medication Errors.
    Bowdle TA, Jelacic S, Nair B. Bowdle TA, et al. Anesthesiology. 2016 Aug;125(2):429-31. doi: 10.1097/ALN.0000000000001185. Anesthesiology. 2016. PMID: 27433762 No abstract available.
  • Adverse Drug Events Link to Severity of the Event Data Needed.
    Ibinson JW, Buffington CW. Ibinson JW, et al. Anesthesiology. 2016 Aug;125(2):431. doi: 10.1097/ALN.0000000000001186. Anesthesiology. 2016. PMID: 27433763 No abstract available.
  • Counting Errors: Medication or Medical?
    Chan YM, Park CS, Youngblood SC. Chan YM, et al. Anesthesiology. 2016 Aug;125(2):431-2. doi: 10.1097/ALN.0000000000001187. Anesthesiology. 2016. PMID: 27433764 No abstract available.
  • In Reply.
    Nanji KC, Bates DW. Nanji KC, et al. Anesthesiology. 2016 Aug;125(2):432-7. doi: 10.1097/ALN.0000000000001188. Anesthesiology. 2016. PMID: 27433765 Free PMC article. No abstract available.
  • A new paradigm for medication error research.
    Feinstein MM, Castro P. Feinstein MM, et al. Br J Anaesth. 2019 Oct;123(4):e483-e484. doi: 10.1016/j.bja.2019.06.015. Epub 2019 Jul 19. Br J Anaesth. 2019. PMID: 31331648 No abstract available.
  • The importance of pharmacists in modern day surgery - editorial.
    Wireko AA, Ohenewaa Tenkorang P, Tope Adebusoye F, Yaa Asieduwaa O, Mehta A, Fosuah Debrah A, Oti VN, Cheng Ng J, Abdul-Rahman T, Sikora V. Wireko AA, et al. Int J Surg. 2023 Feb 1;109(2):88-90. doi: 10.1097/JS9.0000000000000146. Int J Surg. 2023. PMID: 36799812 Free PMC article. No abstract available.

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