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Stipp MM, Deng H, Kong K, Moore S, Hickman RL, Nanji KC. Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events. Medicine (Baltimore) 2022; 101:e31432. [PMID: 36343025 PMCID: PMC9646678 DOI: 10.1097/md.0000000000031432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 09/30/2022] [Indexed: 11/09/2022] Open
Abstract
The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.
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Affiliation(s)
- Melanie M. Stipp
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Hao Deng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
| | - Kathy Kong
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
| | - Sonya Moore
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Karen C. Nanji
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Mass General Brigham, Wellesley, MA, USA
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Tansuwannarat P, Vichiensanth P, Sivarak O, Tongpoo A, Promrungsri P, Sriapha C, Wananukul W, Trakulsrichai S. Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study. Ther Clin Risk Manag 2022; 18:669-681. [PMID: 35795851 PMCID: PMC9252189 DOI: 10.2147/tcrm.s363638] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting. Patients and Methods We performed a 10-year retrospective study (January 2011–December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome. Results In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour–14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs. Conclusion Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.
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Affiliation(s)
- Phantakan Tansuwannarat
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand.,Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piraya Vichiensanth
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ornlatcha Sivarak
- International College, Mahidol University, Nakhon Pathom, 73170, Thailand
| | - Achara Tongpoo
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Puangpak Promrungsri
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Charuwan Sriapha
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Winai Wananukul
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Satariya Trakulsrichai
- Ramathibodi Poison Center, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Webster CS. Existing Knowledge of Medication Error Must Be Better Translated Into Improved Patient Safety. Front Med (Lausanne) 2022; 9:870587. [PMID: 35655855 PMCID: PMC9152084 DOI: 10.3389/fmed.2022.870587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Craig S Webster
- Department of Anaesthesiology and Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand
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Identifying studies on medication error in anaesthesiology. Comment on Br J Anaesth 2021; 127: 458-69. Br J Anaesth 2021; 128:e12-e13. [PMID: 34823873 DOI: 10.1016/j.bja.2021.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/21/2022] Open
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