Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2015.09.006
Brazilian Journal of Anesthesiology
Review Article

Medication errors in anesthesia: unacceptable or unavoidable?

Erros de medicação em anestesia: inaceitável ou inevitável?

Ira Dhawan; Anurag Tewari; Sankalp Sehgal; Ashish Chandra Sinha

http://dx.doi.org/10.1016/j.bjane.2015.09.006 Braz J Anesthesiol, vol.67, n2, p.184-192, 2017
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Abstract

Abstract Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and ‘just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

Keywords

Medical errors, Patient safety, Drug errors, Quality improvement

Resumo

Resumo Os erros de medicação são as causas mais comuns de morbidade e mortalidade dos pacientes. Além disso, esses erros aumentam os encargos financeiros da instituição. Embora o impacto varie de nenhum dano a efeitos adversos graves, inclusive o óbito, é preciso estar atento à ordem de prioridades porque os erros de medicação são evitáveis. Na atualidade, com as pessoas cientes e os processos médicos em evidência, frear esse problema é de extrema prioridade. O esforço individual para diminuir os erros de medicação pode não obter sucesso até que uma mudança nos protocolos e sistemas existentes seja incorporada. Muitas vezes, os erros de medicação ocorridos não podem ser revertidos. A melhor maneira de "tratar" esses erros é impedi-los. Os erros de medicação (devido à troca de seringa), de overdose (devido a mal-entendido ou preconcepção da dose, mal uso de bomba e erro de diluição), de via de administração incorreta, de subdosagem e de omissão são causas comuns de erro de medicação que ocorrem no período perioperatório. A omissão e erros no cálculo de medicamentos ocorrem comumente em UTI. Os erros de medicação podem ocorrer no período perioperatório, tanto durante a preparação e administração quanto na manutenção de registros. Um grande número de erros humanos e do sistema pode ser responsabilizado pela ocorrência de erros de medicação. A necessidade do momento é parar o jogo da culpa, aceitar os erros e desenvolver uma cultura segura e "justa" para evitar os erros de medicação. Os sistemas recém-criados, como o Veinrom, um sistema de administração de líquidos, é uma nova abordagem na prevenção de erros de medicação devido aos medicamentos mais comumente usados em anestesia. Desenvolvimentos semelhantes, juntamente com médicos vigilantes, uma cultura de local de trabalho seguro e apoio organizacional, todos em conjunto podem ajudar a evitar esses erros.

Palavras-chave

Erros médicos, Segurança do paciente, Erros de medicamentos, Melhoria da qualidade

References

Bates DW, Spell N, Cullen DJ. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307-11.

Orser BA, Hyland S, David U. Review article: improving drug safety for patients undergoing anesthesia and surgery. Can J Anesth. 2013;60:127-35.

Webster CS, Merry AF, Larsson L. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29:494-500.

Sakaguchi Y, Tokuda K, Yamaguchi K. Incidence of anesthesia-related medication errors over a 15-year period in a university hospital. Fukuoka Igaku Zasshi. 2008;99:58-66.

Llewellyn RL, Gordon PC, Wheatcroft D. Drug administration errors: a prospective survey from three South African teaching hospitals. Anaesth Intensive Care. 2009;37:93-8.

Cooper L, DiGiovanni N, Schultz L. Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anesth. 2012;59:562-70.

Zhang Y, Dong YJ, Webster CS. The frequency and nature of drug administration error during anaesthesia in a Chinese hospital. Acta Anaesthesiol Scand. 2013;57:158-64.

Cooper L, Nossaman B. Medication errors in anesthesia: a review. Int Anesthesiol Clin. 2013;51:1-12.

Rothschild JM, Landrigan CP, Cronin JW. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-700.

Valentin A, Capuzzo M, Guidet B. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.

Wilmer A, Louie K, Dodek P. Incidence of medication errors and adverse drug events in the ICU: a systematic review. Qual Saf Health Care. 2010;19:e7.

Orser B. Reducing medication error. CMAJ. 2000;162:1150-1.

Skegg PD. Criminal prosecutions of negligent health professionals the New Zealand experience. Med Law Rev. 1998;6:220-46.

Fasting S, Gisvold SE. Adverse drug errors in anaesthesia and the impact of coloured syringe labels. Can J Anesth. 2000;47:1060-7.

Perri M, Morris S. Critical incident involving syringe labels. Anaesthesia. 2007;62:95-6.

Stabile M, Webster CS, Merry AF. Medication administration in anaesthesia. Time for a paradigm shift. APSF Newslett. 2007;22:44-7.

Orser BA, Chen RJ, Yee DA. Medication errors in anaesthetic practice, a survey of 687 practitioners. Can J Anesth. 2001;48:139-46.

Cope RW. The Woolley and Roe case; Woolley and Roe versus Ministry of Health and others. Anaesthesia. 1954;9:249-70.

Maltby JR, Hutter CD, Clayton KC. The Woolley and Roe case. Br J Anaesth. 2000;84:121-6.

Sayers P. Fatal epidural infusion. Anaesth Intensive Care. 2000;28:112.

Ferner RE. Medication errors that have led to manslaughter charges. Br Med J. 2000;321:1212-6.

Currie M, Mackay P, Morgan C. The Australian Incident Monitoring Study. The ‘wrong drug' problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:596-601.

Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277:312-7.

Bordun LA, Butt W. Drug errors in intensive-care. J Paediatr Child Health. 1992;28:309-11.

Kanjanarat P, Winterstein AG, Johns TE. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm. 2003;60:1750-9.

Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83:492-6.

Edgar TA, Lee DS, Cousins DD. Experience with a national medication error reporting program. Am J Hosp Pharm. 1994;51:1335-8.

Fernandez CV, Esau R, Hamilton D. Intrathecal vincristine, an analysis of reasons for recurrent fatal chemotherapeutic error with recommendations for prevention. J Pediatr Hematol Oncol. 1998;20:587-90.

Latif A, Rawat N, Pustavoitau A. National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. Crit Care Med. 2013;41:389-98.

James JTA. New evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122-8.

Cranshaw J, Gupta KJ, Cook TM. Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia. 2009;64:1317-23.

Reason J. Human error. 1990.

Rasmussen J. Information processing and human-machine interaction. 1986.

Regina respondent and Adornako appellant. House of lords appeal cases. 1995;vol. 1:171-90.

Moyen E, Camire E, Stelfox HT. Clinical review: medication errors in critical care. Crit Care. 2008;12:208.

Thaler R, Sunstein C. Nudge: improving decisions about health, wealth and happiness. 2008.

Wegner DM. Ironic processes of mental control. Psychol Rev. 1994;101:34-52.

Merry AF, Shipp DH, Lowinger JS. The contribution of labelling to safe medication administration in anaesthetic practice. Best Pract Res Clin Anaesthesiol. 2011;25:145-59.

Kothari D, Gupta S, Sharma C. Medication error in anaesthesia and critical care: a cause for concern. Indian J Anaesth. 2010;54:187-92.

Cooper JB, Newbower RS, Long CD. Preventable anaesthesia mishaps: a study of human factors. Anesthesiology. 1978;49:399-406.

Abeyasekhra A, Bergman IJ, Kluger MT. Drug error in anaesthesia practice: a review of 896 reports from the Australian incident monitoring study database. Anaesthesia. 2005;6:220-7.

Merry AF, Webster CS, Mathew DJ. A new, safety oriented, integrated drug administration and automated anaesthesia record system. Anesth Analg. 2001;93:385-90.

Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failure in anaesthesia management. Considerations for prevention and detection. Anaesthesiology. 1984;60:34-42.

Sinha A, Singh A, Tewari A. The fatigued anesthesiologist: a threat to patient safety?. J Anaesthesiol Clin Pharmacol. 2013;29:151-9.

Tewari A, Soliz J, Billota F. Does our sleep debt affect patients' safety?. Indian J Anaesth. 2011;55:12-7.

Keers RN, Williams SD, Cooke J. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36:1045-67.

Blendon RJ, DesRoches CM, Brodie M. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-40.

Jensen LS, Merry AF, Webster CS. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;59:493-504.

Eichhorn JH. Medication safety in the operating room: time for a new paradigm. APSF Summit Conference Proceedings. APSF Newslett. 2010;25:1-20.

Tewari A, Palm B, Hines T. VEINROM: a possible solution for erroneous intravenous drug administration. J Anaesthesiol Clin Pharmacol. 2014;30:263-6.

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