Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-24T18:57:13.006Z Has data issue: false hasContentIssue false

1 - Introduction to Medication Safety in Anesthesia and the Perioperative Period

Published online by Cambridge University Press:  09 April 2021

Alan Merry  and
Joyce Wahr
Alan Merry
Affiliation:
University of Auckland
Joyce Wahr
Affiliation:
University of Minnesota
Get access

Summary

Medication errors are believed to be a leading cause of avoidable harm to patients around the world, with an estimated cost of US$42 billion per year, worldwide. It has been estimated that 5% of all patients who are admitted to a hospital experience a medication error, and that an average hospital will have one medication error every 22.7 hours or every 19.7 admissions. Human error is inevitable, but many of these errors actually reflect failures in the design and resourcing of the system within which medications are administered to patients, and some reflect violations of safe medication practices. Medication errors are the most common of all medical errors and pose a tremendous emotional and physical cost to patients and economic burden to our health system. Clearly medication error is a major source of risk and adverse events for our patients. This chapter presents a roadmap for the rest of the book, and definitions that will be used throughout. We also discuss how medication error is measured, the methods by which it is studied, the techniques used to capture incident reports, and some of the metrics and statistics to report these errors and incidents.

Keywords

definitionsmedication errormedication harmerror measurement methodserror metricsincident reportingmedication safety
Type
Chapter
Information
Medication Safety during Anesthesia and the Perioperative Period , pp. 1 - 17
Publisher: Cambridge University Press
Print publication year: 2021

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Donaldson, LJ, Kelley, ET, Dhingra-Kumar, N, Kieny, MP, Sheikh, A. Medication without harm: WHO's third global patient safety challenge. Lancet. 2017;389(10080):1680–1.Google Scholar
World Health Organization (WHO). Medication without harm. WHO's third global patient safety challenge. 2017. Accessed January 3, 2020. https://www.who.int/patientsafety/medication-safety/medication-without-harm-brochure/en/Google Scholar
Bond, CA, Raehl, CL, Franke, T. Medication errors in United States hospitals. Pharmacotherapy. 2001;21(9):1023–36.Google Scholar
Nanji, KC, Patel, A, Shaikh, S, Seger, DL, Bates, DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology. 2016;124(1):25–34.Google Scholar
Brennan, TA, Leape, LL, Laird, NM, et al. Incidence of adverse events and negligence in hospitalized patients – results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370–6.Google Scholar
Leape, LL, Brennan, TA, Laird, N, et al. The nature of adverse events in hospitalized patients – results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377–84.Google Scholar
Choi, I, Lee, SM, Flynn, L, et al. Incidence and treatment costs attributable to medication errors in hospitalized patients. Res Social Adm Pharm. 2016;12(3):428–37.Google Scholar
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(12):1317–23.CrossRefGoogle ScholarPubMed
Wahr, JA, Shore, AD, Harris, LH, et al. Comparison of intensive care unit medication errors reported to the United States’ MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study. Am J Med Qual. 2014;29(1):61–9.CrossRefGoogle Scholar
Schochet, SS Jr, Lampert, PW, Earle, KM. Neuronal changes induced by intrathecal vincristine sulfate. J Neuropathol Exp Neurol. 1968;27(4):645–58.Google Scholar
Gilbar, PJ. Inadvertent intrathecal administration of vincristine: time to finally abolish the syringe. J Oncol Pharm Pract. 2020;26(2):263–6.CrossRefGoogle ScholarPubMed
Dabrowska-Wojciak, I. The death of an infant after the unfortunate intrathecal injection of vincristine. Clin Pract. 2018;15:438–41.Google Scholar
Bain, PG, Lantos, PL, Djurovic, V, West, I. Intrathecal vincristine: a fatal chemotherapeutic error with devastating central nervous system effects. J Neurol. 1991;238(4):230–4.Google Scholar
Trissel, LA, Zhang, Y, Cohen, MR. The stability of diluted vincristine sulfate used as a deterrent to inadvertent intrathecal injection. Hosp Pharm. 2001;36:740–5.Google Scholar
ISMP Canada. Healthcare Insurance Reciprocal of Canada (HIROC). Published data supports dispensing vincristine in minibags as a system safeguard. ISMP Canada; 2001. Accessed January 19, 2020. https://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2001-10Vincristine.pdfGoogle Scholar
World Health Organization. Information Exchange System Alert, No. 115. Geneva: World Health Organization; 2007. Accessed January 19, 2020. https://www.who.int/patientsafety/highlights/PS_alert_115_vincristine.pdfGoogle Scholar
Greenall, J, Shastay, A, Vaida, AJ, et al. Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology. J Oncol Pharm Pract. 2015;21(1):26–35.Google Scholar
Noble, DJ, Donaldson, LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care. 2010;19(4):323–6.Google Scholar
Smetzer, J, Baker, C, Byrne, FD, Cohen, MR. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf. 2010;36(4):152–63.Google Scholar
Arimura, J, Poole, RL, Jeng, M, Rhine, W, Sharek, P. Neonatal heparin overdose – a multidisciplinary team approach to medication error prevention. J Pediatr Pharmacol Ther. 2008;13(2):96–8.Google Scholar
Kennedy, P, Pronovost, P. Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. Crit Care Med. 2006;34(3 suppl):S1–6.Google Scholar
Merry, AF, Webster, CS, Mathew, DJ. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Anesth Analg. 2001;93(2):385–90.Google Scholar
Webster, CS, Merry, AF, Gander, PH, Mann, NK. A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods. Anaesthesia. 2004;59(1):80–7.Google Scholar
Webster, CS, Larsson, L, Frampton, CM, et al. Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study. Anaesthesia. 2010;65(5):490–9.Google Scholar
Merry, AF, Webster, CS, Hannam, J, et al. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ. 2011;343:d5543.CrossRefGoogle ScholarPubMed
Merry, AF, Hannam, JA, Webster, CS, et al. Retesting the hypothesis of a clinical randomized controlled trial in a simulation environment to validate anesthesia simulation in error research (the VASER study). Anesthesiology. 2017;126(3):472–81.Google Scholar
Bowdle, TA, Jelacic, S, Nair, B, et al. Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. Br J Anaesth. 2018;121(6):1338–45.Google Scholar
Australian and New Zealand College of Anaesthetists. PS 51 2018 Guidelines for the Safe Management and Use of Medications in Anaesthesia. Melbourne: Australian and New Zealand College of Anaesthetists; 2018. Accessed April 26, 2019. http://www.anzca.edu.au/resources/professional-documentsGoogle Scholar
Eichhorn, J. APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice. APSF Newsletter. 2010;25(1):1–7. Accessed January 3, 2020. https://www.apsf.org/article/apsf-hosts-medication-safety-conference/Google Scholar
Jensen, LS, Merry, AF, Webster, CS, Weller, J, Larsson, L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004;59(5):493–504.Google Scholar
Wahr, JA, Abernathy, JH 3rd, Lazarra, EH, et al. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth. 2017;118(1):32–43.Google Scholar
Aronson, JK. Medication errors: definitions and classification. Br J Clin Pharmacol. 2009;67(6):599–604.CrossRefGoogle ScholarPubMed
Ferner, RE, Aronson, JK. Clarification of terminology in medication errors: definitions and classification. Drug Saf. 2006;29(11):1011–22.Google Scholar
Pintor-Marmol, A, Baena, MI, Fajardo, PC, et al. Terms used in patient safety related to medication: a literature review. Pharmacoepidemiol Drug Saf. 2012;21(8):799–809.Google Scholar
Lisby, M, Nielsen, LP, Brock, B, Mainz, J. How should medication errors be defined? Development and test of a definition. Scand J Public Health. 2012;40(2):203–10.Google Scholar
Lisby, M, Nielsen, LP, Brock, B, Mainz, J. How are medication errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care. 2010;22(6):507–18.Google Scholar
Anesthesia Patient Safety Foundation. Medication safety in the operating room: Time for a new paradigm. Anesthesia Patient Safety Foundation; 2010. Accessed July 11, 2020. https://www.apsf.org/videos/medication-safety-video/Google Scholar
National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors: What Is a Medication Error? National Coordinating Council for Medication Error Reporting and Prevention. Accessed January 12, 2020. https://www.nccmerp.org/about-medication-errorsGoogle Scholar
Wikipedia contributors. Drug. Wikipedia, The Free Encyclopedia; 2020. Accessed January 12, 2020. https://en.wikipedia.org/w/index.php?title=Drug&oldid=934040601Google Scholar
Morimoto, T, Gandhi, TK, Seger, AC, Hsieh, TC, Bates, DW. Adverse drug events and medication errors: detection and classification methods. Qual Saf Health Care. 2004;13(4):306–14.Google Scholar
Knight, PR 3rd, Bacon, DR. An unexplained death: Hannah Greener and chloroform. Anesthesiology. 2002;96(5):1250–3.Google Scholar
Snow, J. On the fatal cases of inhalation of chloroform. Edinb Med Surg J. 1849;72(180):75–87.Google ScholarPubMed
Snow, J. On chloroform and other anesthetics: their action and administration. Br J Anaesth. 1957;29(3):142–4.Google Scholar
Runciman, WB, Merry, AF. A brief history of the patient safety movement in anaesthesia. In: Eger, E II, Saidman, L, Westhorpe, R, eds. The Wondrous Story of Anesthesia. New York, NY: Springer; 2014:541–56.Google Scholar
Macintosh, R. Deaths under anaesthetics. Br J Anaesth. 1948;21:107–36.Google Scholar
Keats, AS. What do we know about anesthetic mortality? Anesthesiology. 1979;50(5):387–92.CrossRefGoogle ScholarPubMed
Beecher, HK, Todd, DP. A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948–1952, inclusive. Ann Surg. 1954;140(1):2–35.Google Scholar
Dripps, RD, Lamont, A, Eckenhoff, JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261–6.Google Scholar
Clifton, BS, Hotten, WI. Deaths associated with anaesthesia. Br J Anaesth. 1963;35:250–9.Google Scholar
Lagasse, RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology. 2002;97(6):1609–17.Google Scholar
Cooper, JB, Gaba, D. No myth: anesthesia is a model for addressing patient safety. Anesthesiology. 2002;97(6):1335–7.Google Scholar
Bainbridge, D, Martin, J, Arango, M, Cheng, D; Evidence-based Peri-operative Clinical Outcomes Research (EPiCOR) Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380(9847):1075–81.Google Scholar
McNicol, L, ed. Safety of Anaesthesia in Australia. A Review of Anaesthesia Related Mortality 2006 to 2008. Melbourne: Australian and New Zealand College of Anaesthetists; 2017.Google Scholar
Cooper, JB, Newbower, RS, Long, CD, McPeek, B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49(6):399–406.Google Scholar
Newbower, RS, Cooper, JB, Long, CD. Learning from anesthesia mishaps: analysis of critical incidents in anesthesia helps reduce patient risk. QRB Qual. 1981;7(3):10–16.Google ScholarPubMed
Cooper, JB, Long, CD, Newbower, RS, Philip, JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology. 1982;56(6):456–61.Google Scholar
Cooper, JB, Newbower, RS, Kitz, RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology. 1984;60(1):34–42.Google Scholar
Cooper, JB. Toward prevention of anesthetic mishaps. Int Anesthesiol Clin. 1984;22(2):167–83.Google Scholar
Cooper, JB. Anesthesia can be safer: the role of engineering and technology. Med Instrum. 1985;19(3):105–8.Google ScholarPubMed
Gaba, DM, Maxwell, M, DeAnda, A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66(5):670–6.Google Scholar
Pierce, EC Jr. The 34th Rovenstine Lecture. 40 years behind the mask: safety revisited. Anesthesiology. 1996;84(4):965–75.Google Scholar
Eichhorn, J. The APSF at 25: pioneering success in safety but challenges remain. APSF Newsletter. 2010;25(2):1, 23–4, 35–9.Google Scholar
Cooper, J. Patient safety and biomedical engineering. In: Kitz, R, ed. This Is No Humbug: Reminiscences of the Department of Anesthesia at the Massachusetts General Hospital. Boston: Department of Anesthesia and Critical Care, Massachusetts General Hospital; 2002:377–420.Google Scholar
Keers, RN, Williams, SD, Cooke, J, Ashcroft, DM. Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Ann Pharmacother. 2013;47(2):237–56.Google Scholar
Flanagan, JC. The critical incident technique. Psychol Bull. 1954;51:327.Google Scholar
Safren, MA, Chapanis, A. A critical incident study of hospital medication errors. Hospitals. 1960;34:32–4; passim.Google ScholarPubMed
Barker, L, Webb, RK, Runciman, WB, Van der Walt, JH. The oxygen analyser: applications and limitations – an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:570–4.Google Scholar
Cockings, JGL, Webb, RK, Klepper, ID, Currie, M, Morgan, C. Blood pressure monitoring – applications and limitations: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:565–9.Google Scholar
Fox, MAL, Webb, RK, Singleton, R, Ludbrook, G, Runciman, WB. Problems with regional anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:646–9.CrossRefGoogle ScholarPubMed
Holland, R, Webb, RK, Runciman, WB. Oesophageal intubation: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21(5):608–10.Google Scholar
Kluger, MT, Tham, EJ, Coleman, NA, Runciman, WB, Bullock, MF. Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian incident monitoring study. Anaesthesia. 2000;55(12):1173–8.Google Scholar
Currie, M, Mackay, P, Morgan, C, et al. The Australian Incident Monitoring Study. The “wrong drug” problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21(5):596–601.Google Scholar
Currie, M, Webb, RK, Williamson, JA, Russell, WJ, Mackay, P. Clinical anaphylaxis: an analysis of 2000 incident reports. Anaesth Intensive Care. 1993;21:621–5.Google Scholar
Williamson, J, Runciman, B, Hibbert, P, Benveniste, K. AIMS anaesthesia: a comparative analysis of the first 2000 and the most recent 1000 incident reports. ANZCA Bulletin. 2008:13–15. Accessed January 4, 2020. http://www.anzca.edu.au/documents/anzca-bulletin-2008-mar.pdfGoogle Scholar
Eichhorn, JH, Cooper, JB, Cullen, DJ, et al. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256(8):1017–20.Google Scholar
Webster, CS, Merry, AF, Larsson, L, McGrath, KA, Weller, J. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care. 2001;29(5):494–500.Google Scholar
Gibbs, NM, Culwick, M, Merry, AF. A cross-sectional overview of the first 4,000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand. Anaesth Intensive Care. 2017;45(1):28–35.Google Scholar
Gibbs, NM, Culwick, MD, Merry, AF. Patient and procedural factors associated with an increased risk of harm or death in the first 4,000 incidents reported to webAIRS. Anaesth Intensive Care. 2017;45(2):159–65.Google Scholar
Leslie, K, Culwick, MD, Reynolds, H, Hannam, JA, Merry, AF. Awareness during general anaesthesia in the first 4,000 incidents reported to webAIRS. Anaesth Intensive Care. 2017;45(4):441–7.Google Scholar
Guffey, PJ, Culwick, M, Merry, AF. Incident reporting at the local and national level. Int Anesthesiol Clin. 2014;52(1):69–83.Google Scholar
Harkanen, M, Vehvilainen-Julkunen, K, Murrells, T, Rafferty, AM, Franklin, BD. Medication administration errors and mortality: incidents reported in England and Wales between 2007–2016. Res Social Adm Pharm. 2019;15:858–63.Google Scholar
Gallagher, TH, Waterman, AD, Ebers, AG, Fraser, VJ, Levinson, W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001–7.Google Scholar
Sarvadikar, A, Prescott, G, Williams, D. Attitudes to reporting medication error among differing healthcare professionals. Eur J Clin Pharmacol. 2010;66(8):843–53.Google Scholar
Nuckols, TK, Bell, DS, Liu, H, Paddock, SM, Hilborne, LH. Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care. 2007;16(3):164–8.CrossRefGoogle ScholarPubMed
Perez, B, Knych, SA, Weaver, SJ, et al. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. J Patient Saf. 2014;10(1):45–51.Google Scholar
Tingle, J. Improving the National Reporting and Learning System and responses to it. Br J Nurs. 2018;27(5):274–5.Google Scholar
Valentin, A, Capuzzo, M, Guidet, B, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.Google Scholar
al Tehewy, M, Fahim, H, Gad, NI, El Gafary, M, Rahman, SA. Medication administration errors in a university hospital. J Patient Saf. 2016;12(1):34–9.Google Scholar
Orser, BA, Byrick, R. Anesthesia-related medication error: time to take action. Can J Anaesth. 2004;51(8):756–60.Google Scholar
Davis, P, Lay-Yee, R, Briant, R, et al. Adverse events in New Zealand public hospitals I: occurrence and impact. N Z Med J. 2002;115(1167):U271.Google Scholar
Wilson, RM, Runciman, WB, Gibberd, RW, et al. The quality in Australian health care study. Med J Aust. 1995;163:458–71.Google Scholar
Gawande, AA, Thomas, EJ, Zinner, MJ, Brennan, TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126(1):66–75.Google Scholar
Rozich, JD, Haraden, CR, Resar, RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care. 2003;12(3):194–200.CrossRefGoogle Scholar
Cheeseman, JF, Webster, CS, Pawley, MD, et al. Use of a new task-relevant test to assess the effects of shift work and drug labelling formats on anesthesia trainees’ drug recognition and confirmation. Can J Anaesth. 2011;58(1):38–47.CrossRefGoogle ScholarPubMed
Merry, AF, Weller, JM, Robinson, BJ, et al. A simulation design for research evaluating safety innovations in anaesthesia. Anaesthesia. 2008;63(12):1349–57.Google Scholar
Weller, J, Henderson, R, Webster, CS, et al. Building the evidence on simulation validity: comparison of anesthesiologists’ communication patterns in real and simulated cases. Anesthesiology. 2014;120(1):142–8.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×