Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS

2021 ◽  
pp. 0310057X2110275
Author(s):  
Jee Young Kim ◽  
Matthew R Moore ◽  
Martin D Culwick ◽  
Jacqueline A Hannam ◽  
Craig S Webster ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Safety Culture ◽  
Medication Safety ◽  
Reporting System ◽  
Current Evidence ◽  
Contributing Factors ◽  
Incident Reporting System ◽  
Wrong Side ◽  
Inappropriate Choice

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

scholarly journals Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 2

2020 ◽  
Vol 67 (1) ◽  
pp. 48-59
Author(s):  
Daniel S. Sarasin ◽  
Jason W. Brady ◽  
Roy L. Stevens
Keyword(s):  
General Anesthesia ◽  
Medication Errors ◽  
Medication Safety ◽  
Adverse Drug Events ◽  
Contributing Factors ◽  
Full Spectrum ◽  
Dental Profession ◽  
Novel Method ◽  
Dental Providers ◽  
Preventive Methods

For decades, the dental profession has provided the full spectrum of anesthesia services ranging from local anesthesia to general anesthesia in the office-based ambulatory environment to alleviate pain and anxiety. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article illuminated the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medical anesthesia has implemented to manage such problems that may have utility in dentistry, and introduce a novel method for addressing these issues within dentistry known as the Dental Anesthesia Medication Safety Paradigm (DAMSP).

scholarly journals Contributing factors that influence medication errors in the prehospital paramedic environment: a mixed-method systematic review protocol

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e034094
Author(s):  
Dennis Walker ◽  
Clint Moloney ◽  
Brendan SueSee ◽  
Renee Sharples
Keyword(s):  
Systematic Review ◽  
Medication Errors ◽  
Medication Safety ◽  
Data Extraction ◽  
Prehospital Care ◽  
Integrated Approach ◽  
Care Providers ◽  
Contributing Factors ◽  
Multiple Sources ◽  
Qualitative Synthesis

IntroductionThere is limited reliable research available on medication errors in relation to paramedic practice, with most evidence-based medication safety guidelines based on research in nursing, operating theatre and pharmacy settings. While similarities exist, evidence suggests that the prehospital environment is distinctly different in many aspects. The prevention of errors requires attention to factors from the organisational and regulatory level down to specific tasks and patient characteristics. The evidence available suggests errors may occur in up to 12.76% of medication administrations in some prehospital settings. With multiple sources stating that the errors are under-reported, this represents significant potential for patient harm. This review will seek to identify the factors influencing the occurrence of medication errors by paramedics in the prehospital environment.Methods and analysisThe review will include qualitative and quantitative studies involving interventions or phenomena regarding medication errors or medication safety relating to paramedics (including emergency medical technicians and other prehospital care providers) within the prehospital environment. A search will be conducted using MEDLINE (Ovid), EBSCOhost Megafile Search, the International Committee of Medical Journal Editors trial registry, Google Scholar and the OpenGrey database to identify studies meeting this inclusion criteria, with initial searches commencing 30 September 2019. Studies selected will undergo assessment of methodological quality, with data to be extracted from all studies irrespective of quality. Each stage of study selection, appraisal and data extraction will be conducted by two reviewers, with a third reviewer deciding any unresolved conflicts. The review will follow a convergent integrated approach, conducting a single qualitative synthesis of qualitative and ‘qualitised’ quantitative data.Ethics and disseminationNo ethical approval was required for this review. Findings from this systematic review will be disseminated via publications, reports and conference presentations.

Traditional Lectures Actually Improve the Body of Knowledge, Skills, and Attitudes of Health Care Professional for Health Incident Reporting System

2020 ◽  
pp. 001857872091855
Author(s):  
Marcus Vinicius de Souza Joao Luiz ◽  
Fabiana Rossi Varallo ◽  
Celsa Raquel Villaverde Melgarejo ◽  
Tales Rubens de Nadai ◽  
Patricia de Carvalho Mastroianni
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Care Professional ◽  
Safety Culture ◽  
Reporting System ◽  
Patient Safety Culture ◽  
Incident Reporting ◽  
Event Reporting ◽  
Incident Reporting System ◽  
Traditional Lectures

Introduction: A solid patient safety culture lies at the core of an effective event reporting system in a health care setting requiring a professional commitment for event reporting identification. Therefore, health care settings should provide strategies in which continuous health care education comes up as a good alternative. Traditional lectures are usually more convenient in terms of costs, and they allow us to disseminate data, information, and knowledge through a large number of people in the same room. Taking in consideration the tight money budgets in Brazil and other countries, it is relevant to investigate the impact of traditional lectures on the knowledge, skills, and attitudes to incident reporting system and patient safety culture. Objective: The study aim was to assess the traditional lecture impact on the improvement of health care professional competency dimensions (knowledge, skills, and attitudes) and on the number of health care incident reports for better patient safety culture. Participants and Methods: An open-label, nonrandomized trial was conducted in ninety-nine health care professionals who were assessed in terms of their competencies (knowledge, skills, and attitudes) related to the health incident reporting system, before and after education intervention (traditional lectures given over 3 months). Results: All dimensions of professional competencies were improved after traditional lectures ( P < .05, 95% confidence interval). Conclusions: traditional lectures are helpful strategy for the improvement of the competencies for health care incident reporting system and patient safety.

scholarly journals Risk of Medication Errors With Infusion Pumps

2019 ◽  
pp. 61-69
Author(s):  
Matthew Taylor ◽  
Rebecca Jones
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Reporting System ◽  
Risk Mitigation ◽  
Infusion Pump ◽  
Free Text ◽  
Patient Harm ◽  
Infusion Pumps ◽  
Safety Reporting ◽  
Medication Process

The risk of medication errors with infusion pumps is well established, yet a better understanding is needed of the scenarios and factors associated with the errors. Our study explored the frequency of medication errors with infusion pumps, based on events reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) during calendar year 2018. Our study identified a total of 1,004 events involving a medication error and use of an infusion pump, which occurred at 132 different hospitals in Pennsylvania. Fortunately, a majority of medication errors did not cause patient harm or death; however, we did find that 22% of events involved a high-alert medication. Our study shows that the frequency of events varies widely across the stages of medication process and types of medication error. In a subset of our data, we manually reviewed a free-text narrative field in each event report to better understand the nature of errors. For example, we found that a majority of wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor. Overall, results from our study can help providers identify areas to target for risk mitigation related to medication errors and the use of infusion pumps.

scholarly journals MEDICATION ERROR OVERVIEW AND PREVENTION STRATEGIES

2021 ◽  
pp. 19-24
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Safety ◽  
Improve Patient Safety ◽  
Over The Counter ◽  
Reconciliation Analysis ◽  
Prescribing Medication ◽  
Care Costs ◽  
Improve Patient ◽  
Safety Strategy

This literature review aims to highlight the overview of medication errors and strategies to avoid and decrease medication errors. Availability of various types of over-the-counter and prescribed medication has added to the risk of medication. Also, the medication chain has different steps, and different people are involved in each step, such as prescribing medication, dispensing, and administering medication. Every phase in the medication chain is prone to risks that can lead to medication errors. Medication safety is the responsibility of every healthcare professional involved in the medication chain to deliver effective and safe care to patients with an optimal outcome. A medication error can happen in every health care setting to decrease and prevent medication errors. It is critically important to have complete knowledge of the medication use chain and integrate evidence-based strategies, such as medication reconciliation, analysis of medication error, double-check, and avoiding interruption and distraction into practice. Medication errors can lead to patient harm, prevent on-time discharges, and increase care costs. Medication safety culture can shine in a setting of effectively applying strategy into practice, and everyone's collaboration and commitment to adhere to medication safety strategy can improve patient safety.

scholarly journals The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. the Development and Evaluation of an Incident Reporting System in Intensive Care

1996 ◽  
Vol 24 (3) ◽  
pp. 314-319 ◽  
Author(s):  
U. Beckmann ◽  
L. F. West ◽  
G. J. Groombridge ◽  
I. Baldwin ◽  
G. K. Hart ◽  
...  
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
Human Error ◽  
Reporting System ◽  
Contextual Information ◽  
Evaluation Study ◽  
Incident Reporting ◽  
Contributing Factors ◽  
Incident Reporting System ◽  
Incident Monitoring

Intensive care units are complex, dynamic patient management environments. Incidents and accidents can be caused by human error, by problems inherent in complex systems, or by a combination of these. Study objectives were to develop and evaluate an incident reporting system. A report form was designed eliciting a description of the incident, contextual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of earlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback questionnaires were used to assess staff attitudes and understanding, project design and organization. These demonstrated a positive attitude and good understanding by more than 90% participants. Errors in communication, technique, problem recognition and charting were the predisposing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for improving patient safety in intensive care.

scholarly journals Drug Error beyond the Hospital and Role of Pharmacists in drug Safety Process

2019 ◽  
Vol 8 ◽  
pp. 169-176
Author(s):  
Gulam Muhammad Khan
Keyword(s):  
Medication Error ◽  
Medication Safety ◽  
Information Transfer ◽  
Healthcare Professionals ◽  
Hospital Setting ◽  
Outpatient Setting ◽  
Drug Error ◽  
Contributing Factors ◽  
Common Error ◽  
Malpractice Claims

Medication related error is one of the most common error prevailing in this time. Medication error can be defined as a ‘failure in the treatment process that leads to or has potential to lead to harm to the patient. Medication error can occur from the process of ordering to the administration to the patient. Among the healthcare professionals; a pharmacist can be responsible in identification of contributing factors and reducing its occurrence. Great efforts are needed in this area, due to diversity in the types of errors, the relationship between the provider and the patient, information transfer, optimization of e-prescribing systems, the lack of adequate training in analyzing the collected data and poor practical strategies for maintaining accurate drug lists in electronic medical records. Recently healthcare professionals have started becoming aware about the risks of patients’ medication exposure. After all, still the area of medication safety beyond the hospital setting needs community pharmacy intervention to avoid malpractice claims and misled decisions in solving medication safety-related problems in the outpatient setting. Approaches like medication reviews and reconciliation, monitoring drug therapy, reporting error will help in identify and prompt the detection of errors, open productive discussions, quality control checks, and effective system-based decisions like performing risk assessment subsequently reduces the harm and risks before patient is exposed to any form of drug error.

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