Perioperative Medication ErrorsBuilding Safer Systems

Anesthesiology, V 124 • No 1 1 January 2016 I n this month’s issue of Anesthesiology, nanji and coworkers1 present a landmark study that should stimulate discussion and prompt improvements in medication safety in the operating room. the authors performed a prospective, observational clinical trial in a tertiary-care teaching hospital, which measured the frequency of medication errors and adverse drug events during the perioperative period. they reported the numbers of errors and adverse events as percentages of the total number of medications administered. in addition, a retrospective chart review was performed to capture medication errors and adverse events that were missed during the observation period. on the basis of their results, the authors developed recommendations that they believe would have prevented the particular errors and adverse events that were observed during the study. A total of 277 operations were observed, during which a total of 3,671 medications were administered. About 1 in every 20 medications administered involved a drug error and/or an adverse drug event. specifically, a total of 153 medication errors occurred, about one third of which caused an observable adverse drug event (33.3%). A total of 193 medication errors and/or adverse drug events were observed, of which 153 (79%) were preventable and 40 (21%) were not preventable. no medication-related deaths were observed; however, 133 (68.9%) of the observed or potential adverse drug events were serious and 3 (1.6%) were life-threatening. The single most common type of error was a labeling error (37 events; 24.2%). There was no difference in event rates for patients who underwent general anesthesia (227 cases, 82.0% of the total, 3,297 medications administered, 5.3% event rate) and those who underwent sedation only (37 cases, 13.4% of the total, 374 medications administered, 4.6% event rate). one third of the anesthesia care providers were house staff (n = 93, 33.6%); however, no differences in event rates were observed among house staff (68 events, 5.1% event rate), nurse anesthetists (111 events, 5.5% event rate), and staff anesthesiologists (14 events, 4.5% event rate). The high error and adverse event rates reported by nanji and coworkers are surprising and raise several important questions. Why were the rates of medication events substantially higher than those reported in previous studies?2,3 Did observers include trivial events or events that simply reflected a difference in opinion (e.g., choice of drug dose)? Despite the uncertainties, several attributes of the study suggest the high event rates are accurate. First, events were detected by direct third-party observation rather than by self-reporting or facilitated incident reporting (e.g., where reports are completed whether a drug error has occurred). The incidence of errors is typically much higher when events are detected by impartial observers rather than through selfreporting or surveys.4,5 second, the observers who detected the events were fully trained, experienced anesthesia care providers, not less experienced research personnel. Third, Perioperative Medication Errors