Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system

Validation of a natural language processing algorithm using national reporting data to improve identification of anesthesia-related ADVerse evENTs: The "ADVENTURE" study

BACKGROUND

Reporting and analysis of adverse events (AE) is associated with improved health system learning, quality outcomes, and patient safety. Manual text analysis is time-consuming, costly, and prone to human errors. We aimed to demonstrate the feasibility of novel machine learning and natural language processing (NLP) approaches for early predictions of adverse events and provide input to direct quality improvement and patient safety initiatives.

METHODS

We used machine learning to analyze 9559 continuously reported AE by clinicians and healthcare systems to the French National Health accreditor (HAS) between January 1, 2009, and December 31, 2020 . We validated the labeling of 135,000 unique de-identified AE reports and determined the associations between different system's root causes and patient consequences. The model was validated by independent expert anesthesiologists.

RESULTS

The machine learning (ML) and Artificial Intelligence (AI) model trained on 9559 AE datasets accurately categorized 8800 (88%) of reported AE. The three most frequent AE types were "difficult orotracheal intubation" (16.9% of AE reports), "medication error" (10.5%), and "post-induction hypotension" (6.9%). The accuracy of the AI model reached 70.9% sensitivity, 96.6% specificity for "difficult intubation", 43.2% sensitivity, and 98.9% specificity for "medication error."

CONCLUSIONS

This unsupervised ML method provides an accurate, automated, AI-supported search algorithm that ranks and helps to understand complex risk patterns and has greater speed, precision, and clarity when compared to manual human data extraction. Machine learning and Natural language processing (NLP) models can effectively be used to process natural language AE reports and augment expert clinician input. This model can support clinical applications and methodological standards and used to better inform and enhance decision-making for improved risk management and patient safety.

TRIAL REGISTRATION

The study was approved by the ethics committee of the French Society of Anesthesiology (IRB 00010254-2020-20) and the CNIL (CNIL: 118 58 95) and the study was registered with ClinicalTrials.gov (NCT: NCT05185479).

Identifying high-risk medications and error types in Danish patient safety database using disproportionality analysis

BACKGROUND

Medication error (ME) surveillance in Danish healthcare relies on the mandatory national incident reporting system, the Danish Patient Safety Database (DPSD). Individual case reviews and descriptive statistics with frequency counts are the most often used approaches when analyzing MEs in incident reporting systems, including the DPSD. However, incident reporting systems often generate a large number of reports and may suffer from underreporting; consequently, additional approaches are needed to overcome these challenges. Disproportionality analysis (DPA) is a statistical tool used for signal detection of adverse drug reactions in pharmacovigilance reports, but the evidence for using DPA on ME analysis in safety reporting systems is limited.

OBJECTIVES

We aimed to test the feasibility of DPA by analysing harmful MEs reported to DPSD 2014-2018.

METHODS

We utilized proportional reporting ratios (PRR) to identify signals of diproportionality.

RESULTS

We identified well-known high-risk medicines, including anticoagulants, opioids, insulins, antiepileptic, and antipsychotic drugs, and their association with several ME types and stages in a medication process.

CONCLUSION

DPA might be suggested as an additional tool for screening MEs and identifying priority areas for further investigation in safety reporting systems.

Cardiovascular Drug Administration Errors During Neuraxial Anesthesia or Analgesia-A Narrative Review

The prevalence and harm associated with inadvertent neuraxial cardiovascular (CV) medication administration errors are unknown. This review aims to analyze neuraxial CV drug administration errors and associated clinical consequences. The secondary objective is to identify the causes and contributory factors in order to prevent future incidents. The author reviewed reports of accidental administration of CV medications via neuraxial routes during spinal or epidural anesthesia or analgesia published in the last 5 decades (1972-2022). Twenty-seven publications reported neuraxial administration of 10 different CV drugs among patients aged 1 to 81. Seventeen of the 33 errors occurred via the epidural route. Digoxin (9 patients), ephedrine (6), metaraminol (4), labetalol (4), and dopamine (3) were frequently involved in the incidents. Intrathecal digoxin (8 patients) was associated with paraplegia and encephalopathy, of whom 4 pregnant women scheduled for elective cesarean delivery sustained permanent lower limb neurologic deficits. Reversible systemic hemodynamic changes were predominant following the administration of epidural inotropes (dobutamine, dopamine, and epinephrine) and vasopressors (ephedrine and metaraminol). Most administrations (30 out of 32) were only bolus injections. All were preventable skill-based errors. The human factor analysis classification system (HFACS) identified poor organizational climate, inadequate supervision of junior doctors, deficiencies in neuraxial task processes, and incorrect visual perception of objects. The HFACS suggests CV medication safety strategies should include better education and training of junior doctors, modifications in neuraxial anesthesia practices, and careful handling of the CV drug ampoules and syringes.

Extension of patient safety initiatives to perioperative care

PURPOSE OF REVIEW

Patient safety has significantly improved during the intraoperative period thanks to the anesthesiologists, surgeons, and nurses. Nowadays, it is within the perioperative period where most of the preventable harm happened to the surgical patient. We aim to highlight the main issues and efforts to improve perioperative patient safety focusing and the relation to intraoperative safety strategies.

RECENT FINDINGS

There is ongoing research on perioperative safety strategies aiming to initiate multidisciplinary interventions on early stages of the perioperative period as well as an increasing focus on preventing harm from postoperative complications.

SUMMARY

Any patient safety strategy to be implemented needs to be framed beyond the operating room and include in the intervention the whole perioperative period.

Development of Consensus-Based Recommendations to Prevent/Minimize Medication Errors in the Perioperative Care of Patients with Epilepsy: A Mixed-Method

BACKGROUND

This study explored medication errors in the perioperative care of patients with epilepsy and developed consensus-based recommendations to prevent/minimize these errors.

METHODS

A mixed method was used in this study. Medication error situations were explored in semi-structured in-depth interviews with nurses (n = 12), anesthesiologists (n = 5), anesthesia technicians (n = 5), surgeons (n = 4), neurologists (n = 4), and patients with epilepsy (n = 10). The qualitative data were analyzed using the qualitative interpretive description approach. A two-round Delphi technique was used among nurses (n = 22), anesthesiologists (n = 9), anesthesia technicians (n = 7), surgeons (n = 7), and neurologists (n = 5).

RESULTS

A total of 1400 minutes of interview time was analyzed in this study. Of the panelists, 39 (78.0%) agreed that patients with epilepsy present unique challenges to providers of perioperative care that make them prone to medication errors. The interviewees in this study described 32 different medication error situations that occurred while providing perioperative care services to patients with epilepsy. In this study, 35 consensus-based recommendations to prevent/minimize medication errors in the perioperative care of patients with epilepsy were developed.

CONCLUSIONS

The findings of this study are informative to decision-makers in health care facilities and other stakeholders in health regulatory authorities who need to design measures to prevent/minimize medication errors and improve perioperative outcomes of patients with epilepsy. Studies are needed to investigate if these recommendations can be effective in preventing/reducing medication errors in the perioperative care of patients with epilepsy.

A retrospective analysis of peri-operative medication errors from a low-middle income country

Identifying medication errors is one method of improving patient safety. Peri operative anesthetic management of patient includes polypharmacy and the steps followed prior to drug administration. Our objective was to identify, extract and analyze the medication errors (MEs) reported in our critical incident reporting system (CIRS) database over the last 15 years (2004–2018) and to review measures taken for improvement based on the reported errors. CIRS reported from 2004 to 2018 were identified, extracted, and analyzed using descriptive statistics and presented as frequencies and percentages. MEs were identified and entered on a data extraction form which included reporting year, patients age, surgical specialty, American Society of Anesthesiologist (ASA) status, time of incident, phase and type of anesthesia and drug handling, type of error, class of medicine, level of harm, severity of adverse drug event (ADE) and steps taken for improvement. Total MEs reported were 311, medication errors were reported, 163 (52%) errors occurred in ASA II and 90 (29%) ASA III patient, and 133 (43%) during induction. During administration phase 60% MEs occurred and 65% were due to human error. ADEs were found in 86 (28%) reports, 58 of which were significant, 23 serious and five life-threatening errors. The majority of errors involved neuromuscular blockers (32%) and opioids (13%). Sharing of CI and a lesson to be learnt e-mail, colour coded labels, change in medication trolley lay out, decrease in floor stock and high alert labels were the low-cost steps taken to reduce incidents. Medication errors were more frequent during administration. ADEs were occurred in 28% MEs.

Assessment of Medication Errors Among Anesthesia Clinicians in Saudi Arabia: A Cross-Sectional Survey Study

Introduction

Anesthetic drugs are prepared and administrated without referral to the pharmacy or other medical departments. We aimed to assess the occurrence of anesthetic drug errors in Saudi Arabia. We also determined the contributing factors, reporting strategies, and clinicians' opinions of the preventive measures.

Methods

We conducted a cross-sectional web-based survey study using a validated tool. A total of 300 anesthesia clinicians completed the survey (146 anesthesiologists and 154 anesthesia technology specialists). We measured descriptive statistics to describe the demographic characteristics and performed inferential statistics to examine associations and differences.

Results

Sixty-nine percent of respondents had experienced an anesthetic drug error at least once in their career. The two primary factors that caused drug errors were haste (60.3%) and heavy workload (60.3%). On syringe labeling, 56.3% withdrew the drug then labeled the syringe, and 43.7% labeled the syringe then withdrew the drug. The chi-square test revealed that clinicians who labeled the syringe first then withdrew the drug made errors more frequently (p = 0.036). The test also showed that clinicians with less experience had committed more errors (p = 0.015). On reporting drug errors, 77.7% of respondents identified the fear of medicolegal issues as the most common barrier to reporting errors. Respondents believed that double-checking the medication and color-coded syringe labels were the most effective strategies to reduce errors (82% and 64%, respectively). The Mann-Whiney U test revealed significant differences between the two specialties about their opinions of the preventive measures.

Conclusions

There was a high occurrence rate of anesthetic drug errors in Saudi Arabia. Policymakers need to unify the syringe-labeling practice, and future research needs to focus on what makes a nonpunitive culture to encourage reporting errors.

Implementing multidisciplinary tumor boards in oncology: a narrative review

The healthcare industry compares unfavorably with other ultra-safe industries such as aviation and nuclear power plants, which address complexity by reducing the vulnerability of a single person and promoting teams and strong systems. A multidisciplinary tumor board (MTB) is an evidence-based organizational approach to implementing a more effective concept in oncology practice. Studies addressing the correlation between MTBs and cancer outcomes show promising results, and other potential benefits are also addressed. The objectives of this article are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs effectiveness and address challenges to the implementation and maintenance of MTBs. In this commentary-type narrative review, the authors present their opinions and, whenever possible, substantiate recommendations by citing supportive literature.

An integrative review of method types used in the study of medication error during anaesthesia: implications for estimating incidence

To meet the WHO vision of reducing medication errors by 50%, it is essential to know the current error rate. We undertook an integrative review of the literature, using a systematic search strategy. We included studies that provided an estimate of error rate (i.e. both numerator and denominator data), regardless of type of study (e.g. RCT or observational study). Under each method type, we categorised the error rate by type, by classification used by the primary studies (e.g. wrong drug, wrong dose, wrong time), and then pooled numerator and denominator data across studies to obtain an aggregate error rate for each method type. We included a total of 30 studies in this review. Of these, two studies were national audit projects containing relevant data, and for 28 studies we identified five discrete method types: retrospective recall (6), self-reporting (7), observational (5), large databases (7), and observing for drug calculation errors (3). Of these 28 studies we included 22 for a numerical analysis and used six to inform a narrative review. Drug error is recalled by ~1 in 5 anaesthetists as something that happened over their career; in self-reports there is an admitted rate of ~1 in 200 anaesthetics. In observed practice, error is seen in almost every anaesthetic. In large databases, drug error constitutes ~10% of anaesthesia incidents reported. Wrong drug or dose form the most common type of error across all five study method types (especially dosing error in paediatric studies). We conclude that medication error is common in anaesthetic practice, although we were uncertain of the precise frequency or extent of harm. Studies concerning medication error are very heterogenous, and we recommend consideration of standardised reporting as in other research domains.

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study

PURPOSE

To identify factors in community pharmacy that facilitate error recovery from medication incidents (MIs) and explore medication safety prevention strategies from the pharmacist perspective.

METHODS

Thirty community pharmacies in Sydney, Australia, participated in a 30-month prospective incident reporting program of MIs classified in the Advanced Incident Management System (AIMS) and the analysis triangulated with case studies. The main outcome measures were the relative frequencies and patterns in MI detection, minimisation, restorative actions and prevention recommendations of community pharmacists.

RESULTS

Participants reported 1013 incidents with 831 recovered near misses and 165 purported patient harm. MIs were mainly initiated at the prescribing (68.2%) and dispensing (22.6%) stages, and most were resolved at the pharmacy (76.9%). Detection was efficient within the first 24 h in 54.6% of MIs, but 26.1% required one month or longer; 37.2% occurred after the patient consumed the medicine. The combination of specific actions/attributes (85.5%), appropriate interventions (81.6%) and effective communication (77.7%) minimised MIs. An array of remedial actions were conducted by participants including notification, referral, advice, modification of medication regimen, risk management and documentation corrections. Recommended prevention strategies involved espousal of medication safety culture (97.8%), better application of policies/procedures (84.6%) and improvements in healthcare providers' education (79.9%).

CONCLUSION

Incident reporting provided insights on the human and organisational factors involved in the recovery of MIs in community pharmacy. Optimising existing safeguards and redesigning certain structures and processes may enhance the resilience of the medication use system in primary care.

Anaesthesia and perioperative incident reporting systems: Opportunities and challenges

Incident Reporting Systems (IRS) continue to be an important influence on improving patient safety. IRS can provide valuable insights into how to prevent patients from being harmed at the organizational level. But inadequate expectations and misuse, for performance assessment, patient safety measurement or research, have hindered the full IRS potential. Health care organizations need to develop effective strategies built on trust and truth telling to improve the impact of IRS. This requires strategies to address the limited resources to analyse the near-misses or adverse events; avoid the punitive drift through maintaining the anonymity and protective legislation; integrating IRS and avoiding its confusion with mandatory adverse event response systems; training data analysts to focus on the system instead of the individual through a balanced simple taxonomy; combine the analyses at the local level, to reinforce effective and personalized feedback, with the potential of a national or supranational learning platform.