Medication Errors in the Operating Room: An Analysis of Contributing Factors and Related Drugs in Case Reports from a Japanese Medication Error Database.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
01 Mar 2022
01 Mar 2022
Historique:
pubmed:
20
5
2021
medline:
24
2
2022
entrez:
19
5
2021
Statut:
ppublish
Résumé
The aim of this study was to prevent drug-related medication errors in the operating room by clarifying the association between the medication error category with related drugs and contributing factors. We used data from the Japan Council for Quality Health Care's open database on the web. We researched the medication error category, related drugs, and contributing factors. We classified each medication error category into case groups and other medication error categories into control groups. We compared the medication error factors of the 2 groups using multivariate logistic regression analysis on the medication error factors. The total number of analyzed cases was 541. Incorrect dose was the most common medication error category in 170 cases, followed by incorrect drug in 152 cases. Medication error factors (odds ratio, 95% confidence interval) that were found to be significantly positively associated with incorrect dose were "pressor drugs" (3.0, 1.4-6.4), "anesthesia-inducing drugs" (6.3, 1.7-23.4), "lack of knowledge" (2.0, 1.3-3.3), and "drug administration" (3.4, 1.6-7.4). The medication error factors that were found to be significantly positively associated with incorrect drug were "preparation" (5.7, 3.1-10.5) and "medication passed or picked up" (102.2, 35.7-292.8). Medication errors are frequently occurring during drug preparation and administration in the operating room. Medical staff should thoroughly learn about operating room-specific drugs and closely monitor every step of the drug preparation and administration process. It is also important to create a workflow and improve the environment so that it reduces the likelihood of medication errors.
Identifiants
pubmed: 34009873
doi: 10.1097/PTS.0000000000000861
pii: 01209203-202203000-00028
doi:
Substances chimiques
Pharmaceutical Preparations
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e496-e502Informations de copyright
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors disclose no conflict of interest.
Références
Nanji KC, Patel A, Shaikh S, et al. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology . 2016;124:25–34.
Hintong T, Chau-In W, Thienthong S, et al. An analysis of the drug error problem in the Thai Anesthesia Incidents Study (THAI Study). J Med Assoc Thai . 2005;88:118–127.
Cooper L, DiGiovanni N, Schultz L, et al. Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth . 2012;59:562–570.
Llewellyn RL, Gordon PC, Wheatcroft D, et al. Drug administration errors: a prospective survey from three South African teaching hospitals. Anaesth Intensive Care . 2009;37:93–98.
Webster CS, Merry AF, Larsson L, et al. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care . 2001;29:494–500.
Yamamoto M, Ishikawa S, Makita K. Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital. J Anesth . 2008;22:248–252.
Zhang Y, Dong YJ, Webster CS, et al. The frequency and nature of drug administration error during anaesthesia in a Chinese hospital. Acta Anaesthesiol Scand . 2013;57:158–164.
Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anaesth . 2000;47:1060–1067.
Orser BA, Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anaesth . 2001;48:139–146.
Abeysekera A, Bergman IJ, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia . 2005;60:220–227.
Erdmann TR, Garcia JH, Loureiro ML, et al. Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina. Braz J Anesthesiol . 2016;66:105–110.
Ugur E, Kara S, Yildirim S, et al. Medical errors and patient safety in the operating room. J Pak Med Assoc . 2016;66:593–597.
Annie SJ, Thirilogasundary MR, Hemanth Kumar VR. Drug administration errors among anesthesiologists: the burden in India—a questionnaire-based survey. J Anaesthesiol Clin Pharmacol . 2019;35:220–226.
Gelb AW, Morriss WW, Johnson W, et al. World Health Organization–World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesth Analg . 2018;126:2047–2055.
Sumio H. The merits and demerits of each department of anesthesia and the social status of anesthesiologists. J Jpn Soc Clin Anesth . 2019;39:592–596.
The Japan Council for Quality Health Care. Available at: http://www.med-safe.jp/pdf/year_report_english_2005.pdf . Accessed October 20, 2019.
Aronson JK. Medication errors: what they are, how they happen, and how to avoid them. QJM . 2009;102:513–521.
Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med . 2014;6:45–55.
Gariel C, Cogniat B, Desgranges FP, et al. Incidence, characteristics, and predictive factors for medication errors in paediatric anaesthesia: a prospective incident monitoring study. Br J Anaesth . 2018;120:563–570.
Shehata ZH, Sabri NA, Elmelegy AA. Descriptive analysis of medication errors reported to the Egyptian national online reporting system during six months. J Am Med Inform Assoc . 2016;23:366–374.
Suzuki R, Fukatsu S, Ohtsu F. Analysis of contributing factor and related drugs in incidents of excessive dosing or underdosing. Jpn J Pharm Health Care Sci . 2018;44:270–279.
Turbow RM. Adherence to safety protocols protects patients, physicians American Academy of Pediatrics. Available at: https://www.aappublications.org/news/2019/06/20/law062019 . Accessed Novenber 28, 2020.
Banja J. The normalization of deviance in healthcare delivery. Bus Horiz . 2010;53:139–148.
Higham H, Baxendale B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. Br J Anaesth . 2017;119:106–114.
Friedman N, Sagi D, Ziv A, et al. Pediatric residents’ simulation-based training in patient safety during sedation. Eur J Pediatr . 2018;177:1863–1867.
Weller J, Cumin D, Torrie J, et al. Multidisciplinary operating room simulation-based team training to reduce treatment errors: a feasibility study in New Zealand hospitals. N Z Med J . 2015;128:40–51.
Dobson G, Chow L, Filteau L, et al. Guidelines to the Practice of Anesthesia—Revised Edition 2020. Can J Anaesth . 2020;67:64–99.
Merry AF, Johnson WD, Mets B, Morris WW, Gelb AW. The SAFE-T Summit and the International Standards for a Safe Practice of Anesthesia. APSF Newsletter. Avaliable at: https://www.apsf.org/wp-content/uploads/newsletters/2019/3303/APSF3303.pdf . Accessed December 6, 2020.
Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg . 2010;251:976–980.
Hincker A, Ben Abdallah A, Avidan M, et al. Electronic medical record interventions and recurrent perioperative antibiotic administration: a before-and-after study. Can J Anaesth . 2017;64:716–723.
LeRiger MM, Phipps AR, Norton BM, et al. Improving the compliance of intraoperative antibiotic redosing: a quality improvement initiative. Pediatr Qual Saf . 2020;5:e285.
Kim J, Bates DW. Medication administration errors by nurses: adherence to guidelines. J Clin Nurs . 2013;22:590–598.