Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Observational Study
. 2025 Dec 13;26(1):44.
doi: 10.1186/s12871-025-03539-4.

Primary anesthesia provider characteristics and risk factors for intraoperative medication errors: a retrospective cohort study

Kohei Ikeda  1 , Masayoshi Koike  2 , Seirin Yamazaki  2 , Sae Nakamura  2 , Shoichi Uezono  2
Affiliations
Observational Study

Primary anesthesia provider characteristics and risk factors for intraoperative medication errors: a retrospective cohort study

Kohei Ikeda et al. BMC Anesthesiol. .

Abstract

Background: Intraoperative medication errors, although uncommon, can result in considerable patient harm. Evidence remains limited regarding anesthesia provider-level and perioperative risk factors. This study aimed to evaluate whether anesthesia provider characteristics-particularly experience level and team composition-are statistically associated with intraoperative medication errors after multivariable adjustment.

Methods: We conducted a retrospective observational study of 100,093 surgical cases managed under anesthesia at a university-affiliated tertiary hospital in Japan between August 2011 and December 2023. Data were extracted from an electronic anesthesia record system linked to institutional medical records. Medication errors were mainly identified through anesthesia provider self-reporting, supplemented by reports from operating room nurses. Predictor variables included patient characteristics, procedural details, and the main explanatory variable was anesthesia provider configuration: attending, and resident or intern under the supervision of an attending anesthesiologist. Firth's penalized logistic regression was used to adjust for confounding variables identified via a directed acyclic graph.

Results: Intraoperative medication errors occurred in 102 of 100,093 procedures (0.10%). Compared with attending anesthesiologists, the odds of medication error-adjusted for the familywise error rate (FWER) using the Holm-Bonferroni method-were significantly higher when care involved residents [OR 2.713; 95% CI, 1.283-6.815; P = 0.007] or interns [OR 3.272; 95% CI, 1.508-8.368; P = 0.003]. After multiplicity adjustment, no other factors-including age, American Society of Anesthesiologists Physical Status (ASA-PS) classification, and surgical urgency-were statistically associated with error risk. Sensitivity analyses confirmed the robustness of the main findings across different covariate sets.

Conclusions: Anesthesia provider characteristics were statistically associated with intraoperative medication error risk. These findings suggest the need for strengthened supervision, structured team roles, and systems-based safeguards in perioperative medication safety.

Keywords: Anesthesia provider experience; Anesthesia safety; Firth’s penalized logistic regression; Intraoperative medication errors; Patient safety; Retrospective cohort study.

PubMed Disclaimer

Conflict of interest statement

Declarations. Ethics approval and consent to participate: This retrospective study was approved by the Ethics Committee of The Jikei University School of Medicine for Biomedical Research (approval No. 36–143[12252]). The need for individual informed consent was waived by the Committee, and public disclosure with an opt-out option was implemented in accordance with the Committee’s instructions. The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable. This study did not include any individual person’s data in any form (including images, videos, or personal details). Competing interests: The authors declare no competing interests. Conflict of interest: The authors declare that they have no conflicts of interest.

Figures

Fig. 1
Fig. 1
Flow diagram illustrating case selection and exclusion criteria. Of 101,549 surgical cases managed by the Department of Anesthesiology during the study period, 1,456 were excluded due to minor procedures such as central venous catheterization (n = 921), aborted surgery (n = 67), non-anesthesiology primary providers (n = 462), or missing data for covariates (n = 6). A total of 100,093 cases were included in the final analysis, comprising 102 cases with intraoperative medication errors and 99,991 without errors. CVC, central venous catheterization
See this image and copyright information in PMC

References

    1. Challenge WGPS. Medication without harm. World Health Organization. 2017. https://www.who.int/initiatives/medication-without-harm.
    1. Cooper L, DiGiovanni N, Schultz L, Taylor AM, Nossaman B. Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth. 2012;59(6):562–70. - DOI - PubMed
    1. Wahr JA, Prager RL, Abernathy JH 3, Martinez EA, Salas E, Seifert PC, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation. 2013;128(10):1139–69. - DOI - PubMed
    1. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694–700. - DOI - PubMed
    1. Llewellyn RL, Gordon PC, Wheatcroft D, Lines D, Reed A, Butt AD, et al. Drug administration errors: a prospective survey from three South African teaching hospitals. Anaesth Intensive Care. 2009;37(1):93–8. - DOI - PubMed

Publication types

LinkOut - more resources