Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study

BACKGROUND

Drug administration errors (DAEs) in anaesthesia are common, the aetiology multifactorial and though mostly inconsequential, some lead to substantial harm. The extend of DAEs remain poorly quantified and effective implementation of prevention strategies sparse.

METHOD

A cross-sectional descriptive study was conducted using a peer-reviewed survey questionnaire, circulated to 2217 anaesthetists via a national communication platform. The aim was to determine the self-reported frequency, nature, contributing factors and reporting patterns of DAEs among anaesthesia providers in South Africa.

RESULTS

Our cohort had a response rate was 18.9%, with 420 individuals populating the questionnaire. 92.5% of surveyed participants have made a DAE and 89.2% a near-miss. Incorrect route of administration, potentially resulting in serious harm, accounted for 8.2% (n = 23/N = 279) of these errors. DAEs mostly reported in cases involving adult patients (80.5%, n = 243/N = 302), receiving a general anaesthetic (71.8%, n = 216/N = 301), where the drug-administrator prepared the drugs themselves (78.7%, n = 218/N = 277), during normal daytime hours (69.9%, n = 202/N = 289) with good lightning conditions (93.0%, n = 265/N = 285). 26% (n = 80/N = 305) of DAEs involved ampoule misidentification, whilst syringe identification error reported in 51.6% (n = 150/N = 291) of cases. DAEs are often not reported (40.3%, n = 114/N = 283), with knowledge of correct reporting procedures lacking. 70.5% (n = 198/N = 281) of DAEs were never discussed with the patient.

CONCLUSIONS

DAEs in anaesthesia remain prevalent. Known error traps continue to drive these incidents. Implementation of system based preventative strategies are paramount to guard against human error. Efforts should be made to encourage scrupulous reporting and training of anaesthesia providers, with the aim of rendering them proficient and resilient to handle these events.

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).

Inadvertent administration of intravenous anaesthesia induction agents via the intracerebroventricular, neuraxial or peripheral nerve route - A narrative review

Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high-risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration.

Medication errors in veterinary anesthesia: a literature review

OBJECTIVE

To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction.

DATABASES USED

PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗].

CONCLUSIONS

Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Intraoperative Opioid Waste and Association of Intraoperative Opioid Dose with Postoperative Adverse Outcomes: A Hospital Registry Study

INTRODUCTION

Perioperative opioid use has been associated with adverse clinical outcomes. Additionally, opioid disposal carries significant costs, due to the waste of pharmaceutical products and the time needed by skilled labor to report the waste. In this study, we aimed to estimate costs and predict factors of opioid-associated intraoperative product waste, as well as to evaluate whether higher intraoperative opioid doses are associated with increased risk of adverse postoperative outcomes.

METHODS

We included 170,607 patients undergoing general anesthesia and receiving intraoperative fentanyl, hydromorphone, or morphine at Beth Israel Deaconess Medical Center, Boston, MA, USA, between January 2010 and June 2020. We estimated product waste-associated costs based on various opioid syringe sizes and determined predictors of opioid waste. Further, we evaluated whether higher opioid doses were associated with postoperative adverse events according to the severity-indexed, incident report-based medication error-reporting program classification. The primary outcome included post-extubation desaturation, postoperative nausea or vomiting, or postoperative somnolence or sedation.

RESULTS

The use of the smallest syringe sizes (50 mcg for fentanyl, 0.2 mg for hydromorphone, and 2 mg for morphine) resulted in the lowest product waste-associated costs. The main predictor of opioid waste was the administration of more than one intraoperative opioid (adjusted odds ratio [aOR] = 7.64, 95% CI 7.40-7.89, P < 0.001). Intraoperative doses of fentanyl > 50-100 mcg (aOR = 1.17 [1.10-1.25], P < 0.001, adjusted risk difference [ARD] 2%) and > 100 mcg (aOR = 1.24 [1.16-1.33], P < 0.001, ARD 3%), hydromorphone > 1 mg (aOR = 1.13 [1.06-1.20], P < 0.001, ARD 2%), and morphine > 2-4 mg (aOR = 1.26 [1.02-1.56], P = 0.04, ARD 3%) and > 4 mg (aOR = 1.45 [1.18-1.77], P < 0.001, ARD 5%) were associated with higher risk of the primary outcome.

CONCLUSION

Smaller syringe sizes of intraoperative opioids may help to reduce product waste and associated costs, as well postoperative adverse events through utilization of lower intraoperative opioid doses.

Evaluation of a Course to Teach Medical Students Latent Hazard Identification in the Operating Room

INTRODUCTION

To improve situational awareness in the operating room (OR), a virtual online operating room of hazards (ROH) with deliberately placed risks was created. We hypothesized that subjects first participating in the virtual online ROH would identify more hazards during an in-person ROH exercise in a physical OR than those in the control group who only received didactic training.

METHODS

We conducted a randomized controlled trial at a major academic medical center, enrolling 48 pre-clinical medical students with no previous OR exposure during their classes. Control and experimental group subjects participated in a brief, online didactic orientation session conducted live over Zoom (Zoom Video Communications, Inc., San Jose, CA) to learn about latent hazards in the OR. Experimental group subjects further interacted with a virtual online operating ROH in which latent hazards were present. The fraction of deliberately created latent hazards placed in a physical, in-person OR identified by subjects was calculated.

RESULTS

Experimental group subjects identified a significantly larger fraction of the created hazards (41.3%) than the control group (difference = 16.4%, 95% CI: 11.3% to 21.4%, P < 0.0001). There was no difference in the number of non-hazards misidentified as hazards between the groups.

CONCLUSIONS

Participation in the virtual online environment resulted in greater recognition of latent operating room hazards during a simulation conducted in a physical, in-person OR than in a didactic experience alone. Because creating an in-room experience to teach the identification of latent hazards in an OR is resource-intensive and requires removing the OR from clinical use, we recommend the virtual online approach described for training purposes. Adding items most misidentified as hazards is suggested for future implementation.

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions

BACKGROUND

Look-alike medications, where ampoules or vials of intravenous medications look similar, may increase the risk of medication errors in the perioperative setting.

AIM

This scoping review aimed to identify and explore the issues related to look-alike medication incidents in the perioperative setting and the reported risk reduction interventions.

METHOD

Eight databases were searched including: CINAHL Complete, Embase, OVID Emcare, Pubmed, Scopus, Informit, Cochrane and Prospero and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR). Key search terms included anaesthesia, adverse drug event, drug error or medication error, look alike sound alike, operating theatres and pharmacy. Title and abstracts were screened independently and findings were extracted using validated tools in collaboration and consensus with co-authors.

RESULTS

A total of 2567 records were identified to 4th July 2022; however only 18 publications met the inclusion criteria. Publication types consisted of case reports, letters to the editor, multimodal quality improvement activities or survey/audits, a controlled simulation study and one randomised clinical trial. Risk reduction intervention themes identified included regulation, procurement, standardisation of storage, labelling, environmental factors, teamwork factors and the safe administration.

CONCLUSION

This review highlighted challenges with look-alike medications in the perioperative setting and identified interventions for risk reduction. Key interventions did not involve technology-based solutions and further research is required to assess their effectiveness in preventing patient harm.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists

Peri-operative medication safety is complex. Avoidance of medication errors is both system- and practitioner-based, and many departments within the hospital contribute to safe and effective systems. For the individual anaesthetist, drawing up, labelling and then the correct administration of medications are key components in a patient's peri-operative journey. These guidelines aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors. The aim is that they will be used as a basis for instilling good practice.

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century

We review the development of technology in anaesthesia over the course of the past century, from the invention of the Boyle apparatus to the modern anaesthetic workstation with artificial intelligence assistance. We define the operating theatre as a socio-technical system, being necessarily comprised of human and technological parts, the ongoing development of which has led to a reduction in mortality during anaesthesia by an order of four magnitudes over a century. The remarkable technological advances in anaesthesia have been accompanied by important paradigm shifts in the approach to patient safety, and we describe the inter-relationship between technology and the human work environment in the development of such paradigm shifts, including the systems approach and organisational resilience. A better understanding of emerging technological advances and their effects on patient safety will allow anaesthesia to continue to be a leader in both patient safety and in the design of equipment and workspaces.

Evaluation of Detected Medication Errors Within the Operating Room at an Academic Medical Center

Background: Medication errors are preventable events that lead to inappropriate medication use and potential patient harm. This is especially prevalent within the operating room (OR) where one practitioner is involved in the entire medication-use process. Despite recent implementation of BD Pyxis™ Anesthesia ES, Codonics Safe Label System, and Epic One Step at the University of Kentucky Healthcare (UKHC) to prevent medication errors, errors continue to be reported. Curatolo et al found human error was the most frequent cause of medication error within the OR. Clumsy automation may be an explanation for this, which imposes burdens and promotes work arounds. This study endeavors to assess potential medication errors via chart review to identify risk reduction strategies. Methods: This a single-center retrospective cohort review of patients admitted to a UK HealthCare Main Operating Room, defined OR1A-OR5A and OR7A-OR16A, who were administered medications from 8/1/2021 to 9/30/2021. Results: Over a 2-month period, 145 cases were conducted at UK HealthCare. Of the 145 cases, 98.6% (n = 143) involved a medication error and 93.7% (n = 136) of the errors involved a high-alert medication. The top 5 classes of drugs involved in errors were all high-alert medications. Lastly, 46.6% (n = 67) of cases had documentation that Codonics was utilized. In addition to analyzing medication errors, the financial analysis found that $3154.04 in drug cost was lost in the study period. When extrapolating these results to all BD™ Pyxis Anesthesia Machines at UK HealthCare, $107 237.36 of drug cost is potentially lost per year. Conclusions: These findings add to previous data that have described the increased rate of medication errors when conducting chart review rather than rely on self-reported data. In this study, 98.6% of all cases involved a medication error. In addition, these findings provide additional insight in the increased use of technology within the operating room despite medication errors still occurring. These results can be applied to like institutions to critically evaluate anesthesia workflow to determine risk reduction strategies.

Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia: A narrative review of 22 recent reports

Therapeutic use of tranexamic acid (TXA) to minimise blood loss is common during a wide range of surgical procedures. This review aims to explore the clinical features of the accidental intrathecal administration of TXA and to identify contributory factors that might prevent future incidents. The author searched published reports of accidental intrathecal administration of TXA using Medline and Google Scholar databases from July 2018 to September 2022, including error reports in any language but excluding errors via nonintrathecal routes. The human factors analysis classification system (HFACS) framework was used to examine and classify the human and systemic factors that contributed to the errors. Twenty-two errors of accidental intrathecal administration were reported during the search period. The analysis showed that the outcome was death in eight patients (36%) and permanent harm in four (19%). The fatality rate was higher among female individuals (6/13 versus 2/8 male individuals). Two-thirds of errors (15/22) occurred during orthopaedic surgery (10) and lower segment caesarean sections (5). Nineteen of 21 patients developed refractory or super refractory status epilepticus, requiring mechanical ventilation and intensive care for 3 days to 3 weeks for those who survived the initial few hours. Severe sympathetic stimulation resulting in refractory ventricular arrhythmias was the final event in some patients, with death within a few hours. Lack of familiarity with clinical characteristics caused delayed diagnosis or confusion with other clinical conditions. A proposed plan to manage intrathecal TXA toxicity is presented, including immediate cerebrospinal fluid lavage; however, there is no specific approach. The HFACS suggested mistaking look-alike TXA ampoules for local anaesthetic was the predominant cause. The author concludes that inadvertent intrathecal TXA is associated with mortality or permanent harm in more than 50% of patients. The HFACS demonstrates that all errors are preventable.

Medication safety in pediatric anesthesia: An educational review and a call to action

Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.

Consensus on the Southeast Asian management of hypotension using vasopressors and adjunct modalities during cesarean section under spinal anesthesia

BACKGROUND AND AIMS

This consensus statement presents a comprehensive and evidence-based set of guidelines that modify the general European or US guidelines for hypotension management with vasopressors during cesarean delivery. It is tailored to the Southeast Asian context in terms of local human and medical resources, health system capacity, and local values and preferences.

METHODS AND RESULTS

These guidelines were prepared using a methodological approach. Two principal sources were used to obtain the evidence: scientific evidence and opinion-based evidence. A team of five anesthesia experts from Vietnam, the Philippines, and Thailand came together to define relevant clinical questions; search for literature-based evidence using the MEDLINE, Scopus, Google Scholar, and Cochrane libraries; evaluate existing guidelines; and contextualize recommendations for the Southeast Asian region. Furthermore, a survey was developed and distributed among 183 practitioners in the captioned countries to gather representative opinions of the medical community and identify best practices for the management of hypotension with vasopressors during cesarean section under spinal anesthesia.

CONCLUSIONS

This consensus statement advocates proactive management of maternal hypotension during cesarean section after spinal anesthesia, which can be detrimental for both the mother and fetus, supports the choice of phenylephrine as a first-line vasopressor and offers a perspective on the use of prefilled syringes in the Southeast Asian region, where factors such as healthcare features, availability, patient safety, and cost should be considered.

Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse medication events

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.

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.

Feasibility of Virtual Simulation-Based Diabetes Foot Care Education in Patients with Diabetes in Ethiopia: Protocol for a Randomized Controlled Trial

INTRODUCTION

Diabetes mellitus is a rapidly growing global public health problem; the number of adults with diabetes is expected to increase from 424.9 million in 2017 to 628.6 million in 2045. Approximately 80% of diabetic patients live in low- and middle-income countries where access to care may be limited. For example, in Ethiopia, diabetes care is often rudimentary, and formal, structured diabetes education is almost non-existent. One potential solution to the lack of diabetes management education for patients could be virtual simulation-based diabetes education incorporating the contextual realities of patients in Ethiopia. Despite its great potential to improve glycemic control, delay diabetes-related complications and reduce mortality associated with diabetes, the feasibility of virtual simulation-based diabetes self-management education has not been studied in low- and middle-income settings.

OBJECTIVE

The purpose of the current study is to evaluate the feasibility of a virtual simulation-based Diabetes Foot Care Education (DFCE) program among adult patients with diabetes in Ethiopia.

METHODS

A randomized controlled feasibility study including participants from University of Gondar Referral Hospital (UoGRH) will be conducted. A sample of 40 participants will be recruited, of which 20 participants will receive the virtual simulation-based education program, and the other 20 participants will continue with their usual diabetes care. After the education program, a questionnaire and structured interview will be used to explore the feasibility (acceptability, practicality) and the potential impact of virtual simulation-based DFCE intervention in patients with diabetes. Data will be analyzed using SPSS version 25 using descriptive statistics, independent t-tests, paired sample t-test, and factorial ANOVA at significance levels of less than 0.05.

DISCUSSION

Our study seeks to understand the perceived usefullness and usability of virtual simulation-based diabetes foot care education on behavioural (diabetes foot-care knowledge, foot self-care practices, and foot self-care efficacy). Furthermore, the study will provide insight to assist in the development of technologically assisted and contextually designed DFCE programs.

TRIAL REGISTRATION NUMBER

NCT04841291 (ClinicalTrials.gov Identifier).

Medication Errors in Anesthesiology: Is It Time to Train by Example? Vignettes Can Assess Error Awareness, Assessment of Harm, Disclosure, and Reporting Practices

BACKGROUND

Perioperative medication errors (MEs) are complex, multifactorial, and a significant source of in-hospital patient morbidity. Anesthesiologists' awareness of error and the potential for harm is not well understood, nor is their attitude to reporting and disclosure. Anesthesiologists are not routinely exposed to medication safety training.

METHODS

Ten clinical vignettes, describing an ME or a near miss, were developed using eDelphi consensus. An online survey instrument presented these vignettes to anesthesiologists along with a series of questions assessing error awareness, potential harm severity, the likelihood of reporting, and the likelihood of open disclosure to the patient. The study also explored the influence of prior medication safety training.

RESULTS

Eighty-nine anesthesiologists from 14 hospitals across Ireland (53.9% were residents, and 46.1% were attendings) completed the survey. Just 35.6% of anesthesiologists recalled having had medication safety training, more commonly among residents than attendings, although this failed to reach significance (P < 0.081). Medication error awareness varied with the vignette presented. Harm severity assessment was positively associated with error awareness. The likelihood of patient disclosure and incident reporting was both low and independent of harm severity assessment.

CONCLUSIONS

Perioperative ME awareness and assessment of potential harm by anesthesiologists is variable. Self-reported rates of incident reporting and error disclosure fall short of the standards that might apply in an environment focused on candor and safety. An extensive education program is required to raise awareness of error and embed appropriate reporting and disclosure behaviors. Vignettes, designed by consensus, may be valuable in the delivery of such a curriculum.

Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

A Monte Carlo Simulation to Estimate the Additional Cost Associated With Adverse Medication Events Leading to Intraoperative Hypotension and/or Hypertension in the United States

OBJECTIVES

Intraoperative hypertension and hypotension are common and often related to adverse medication events (AMEs). The study objective is to estimate the annual additional fully allocated costs to the U.S. healthcare system related to AMEs associated with clinically significant intraoperative hypertension and hypotension.

METHODS

Using anesthesia-trained observers in randomly selected operating rooms, we estimated the rates of clinically significant intraoperative hypotension and hypertension. We conducted systematic literature reviews to estimate incidence and additional costs of acute kidney injury (AKI), acute myocardial injury, and stroke after intraoperative hypotension and hypertension. We used Monte Carlo simulation to estimate annual costs to the U.S. healthcare system.

RESULTS

Intraoperative hypotension (mean arterial pressure <55 mm Hg for >6 minutes) occurred in 11 of 277 operations (3.97%), hypotension (>30% drop from baseline mean arterial pressure in patients with coronary artery disease) in 9 operations (3.25%) and hypertension in 14 operations (5.05%). After hypotension, incremental incidence of AKI was 1.46% (additional cost $17,289/case), acute myocardial injury was 0.75% ($21,340/case), and stroke was 0.05% ($19,903/case). After hypertension, incremental stroke incidence was 4.76% ($28,320/case). Annually in the United States, we estimated 11,513 cases of AKI, 5914 of acute myocardial injury, 345 of stroke after intraoperative hypotension, and 47,774 cases of stroke after intraoperative hypertension, costing the U.S. $1.7 billion (90% confidence interval, $1.4-$2.0 billion), of which $923 million (90% confidence interval, $763-$1101 million) is preventable.

CONCLUSIONS

Adverse medication events related to blood pressure are frequent, costly, and can cause considerable patient harm. Cost estimates for these events may provide a means of prioritizing safety improvements to reduce cost of care and improve patient outcomes.

Human errors and their prevention in healthcare

Human errors form a significant portion of preventable mishaps in healthcare. Even the most competent clinicians are not immune to it. Errors in the perioperative period can often have grave consequences, and hence, perioperative clinicians need to be aware of the impact of human errors and how to minimize them. Errors are broadly classified into two kinds: latent and active errors. While active errors need to be addressed at the individual level, latent errors indicate organizational inadequacies. This review describes common errors in perioperative settings, the impact of such errors on healthcare, and preventive strategies to minimize such errors in daily patient care.

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

Narrative review of neuraxial potassium chloride administration errors: clinical features, human factors, and prevention measures

BACKGROUND

Administration of the wrong drug via the epidural or intrathecal route can cause devastating consequences. Because of the commonality of potassium replacement therapy coupled to its potential neurotoxic profile, we suspected that injuries related to this drug error would be present in the literature.

OBJECTIVES

We aimed to identify clinical characteristics associated with the inadvertent administration of potassium chloride (KCl) during neuraxial anesthesia. Our secondary objective was to identify human factors that may have been associated.

EVIDENCE REVIEW

Published reports of neuraxial administration of KCl in humans were searched using Medline and Google Scholar. Error reports in any language were included.

FINDINGS

25 case reports/series reported administration of KCl via epidural (25 patients) or intrathecal routes (three patients). There were six cases during interventional pain procedures, five cases in operating rooms and 17 in wards or intensive care units. Neuraxial KCl caused paraplegia in 22 patients. Mechanical ventilation was instituted in 11 of 28 patients. Three patients died. Epidural (eight patients) and spinal (two patients) lavage were performed to minimize consequences. A correctly prepared KCl infusion was connected to the epidural catheter for nine patients on wards (32%; 95% upper confidence limit: 48%) due to epidural-intravenous line confusion. Among the other 19 errors, KCl was confused with normal saline for 13 patients or local anesthetic in three patients. A wide range of concentrations and doses of KCl were administered. Variable use of intravenous steroid (13 patients) and epidural saline (eight patients) was found among patients who received epidural KCl. Human factors identified included incorrect visual perception, inadequate monitoring of infusions and substandard practice related to neuraxial anesthesia or analgesia.

CONCLUSIONS

KCl administration via epidural or intrathecal route has been reported to cause catastrophic consequences.

Medication safety in nonoperating room anesthesiology

PURPOSE OF REVIEW

Medication errors remain a prominent source of medical harm in spite of over 20 years of effort in establishing standardized protocols and procedures, implementing assistive electronic technologies to identify medications and prevent administration errors and in establishing a just culture with regard to reporting events and near misses.

RECENT FINDINGS

Some of these interventions are even more necessary in the nonstandard environment of a non-operating room anesthesiology (NORA) procedure suite, where the anesthesiologist is often far removed from colleagues, in a dark room, lacking the standard medications commonly found in their operating room. Medication availability in NORA sites may be limited because of lack of standardization or distance from the operating room pharmacy. Proper preparation of medication may be impaired by poor lighting and cramped conditions. Medication administration might be hampered by a lack of infusion pumps or pumps without the proper medication library needed by the anesthesiologist.

SUMMARY

Specific attention must be paid to enhancement of medication safety in NORA sites to overcome additional challenges inherent in the provision of anesthesia care remote from the standard operating room setting.

Distraction in the operating room: A narrative review of environmental and self-initiated distractions and their effect on anesthesia providers

The operating room (OR) is a busy environment with multiple opportunities for distraction. A well-trained anesthesiologist or certified registered nurse anesthetist (CRNA) should remain focused on providing excellent patient care despite these potential distractions. The purpose of this narrative review is to present the multiple types of OR distractions and evaluate each for their level of distraction and their likely impact on patient safety. Distractions in the OR are common and numerous types of distractions exist. Loud OR background noise can lead to miscommunication within the OR team. In several studies, OR noise has been shown to decrease vigilance and possibly delay recognition of non-routine events. The most commonly observed distracting events are "small talk" and staff entering and exiting the OR and most intense distracting events are faulty or unavailable equipment. Phone and pager use can be particularly distracting. Self-initiated distractions can be seen as unprofessional and can negatively impact patient safety. The impact of OR distractions on patient outcomes deserves more vigorous investigation. We must provide anesthesia trainees with the skills to remain vigilant despite numerous and varied OR distractions while also attempting to reduce such OR distractions to improve patient safety. Further research is needed to inform the institution of policies to lessen unnecessary OR distractions.

Back to Basics: Medication Safety

Perioperative nurses administer some medications but are primarily responsible for obtaining, preparing, and documenting medications. Unlike personnel in many other patient care areas, perioperative personnel may not have immediate access to a pharmacist; this lack of pharmacy support can complicate medication administration processes. A variety of medication errors occur in the perioperative setting and can negatively affect patients and personnel. Perioperative nurses should review regulatory information and professional organization guidance documents when they work with other health care team members to address medication safety issues. Some recommendations include submitting clear medication orders, using aseptic technique when transferring medications to the sterile field, and using standardized labeling. In addition, perioperative nurses should obtain only one patient's medications from a dispensing unit at a time and prepare one medication at a time. After reviewing this article and the supporting literature, perioperative nurses should have increased knowledge about medication safety.

Survey of the Preparation of Cardiovascular Emergency Medications for Adult Cardiovascular Anesthesia

OBJECTIVES

To describe current practices and safety concerns regarding cardiac emergency medications in cardiac anesthesia.

DESIGN

An anonymous survey with multiple-choice questions.

SETTINGS

Online survey using Opinio platform.

PARTICIPANTS

Cardiac anesthesiologists from United States and Canada.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Response rate was 12% (n = 320), with 78% of respondents from the United States and 22% from Canada. The majority of the respondents were experienced (66%), academic (60%), and worked in large cardiac institutions (81%). Most cardiac emergency medications were prepared in the operating room (53.4%), followed by the pharmacy (34%) and industry (8.2%). American respondents had more medications prepared by a pharmacy (53%) versus Canadian (10%, p < 0.001). The majority (85%) considered expiration time of cardiac medications prepared in the operating room to be more than 12 hours. Familiarity with the American Society of Anesthesiologists guidelines on labeling was 58%, other medication safety guidelines 25%, and 34% were not familiar with any guidelines. The majority used color-coded labeling (95%), and a minority (11%) used bar-code systems. Most respondents (69%) agreed that lack of availability of preprepared medications could compromise patient safety. Having to prepare medications by themselves was a concern for respondents based on distractions (66%), lack of availability for emergencies (53%), labeling errors (41%), incorrect concentration (36%), sterility (33%), and stability (30%).

CONCLUSION

This survey found that cardiac emergency medications commonly are prepared in the operating room. The authors identified gaps in familiarity with parenteral medications safety guidelines. Most safety concerns could be addressed with the application of current medication safety guidelines.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Global PRoMiSe (Perioperative Recommendations for Medication Safety): protocol for a mixed-methods study

INTRODUCTION

Medication errors (MEs), which occur commonly in the perioperative period, have the potential to cause patient harm or death. Many published recommendations exist for preventing perioperative MEs; however, many of these recommendations conflict and are often not applicable to middle-income and low-income countries. The goal of this study is to develop and disseminate consensus-based recommendations for perioperative medication safety that are tailored to country income level.

METHODS AND ANALYSIS

The primary site of this mixed-methods study is Massachusetts General Hospital/Harvard Medical School. Participants include a minimum of 108 international medication safety experts, 27 from each of the World Bank's four country income groups (high, upper-middle, lower-middle and low-income). Using the Delphi method, participants will rate the appropriateness of candidate medication safety recommendations by completing online surveys using RedCAP. We will use Condorcet ranking methods to prioritise the final recommendations for each country income group. We will execute a comprehensive dissemination strategy for the recommendations across each country income group. Finally, we will conduct semistructured interviews with our participants to evaluate the initial adoption and implementation of the recommendations in each country income group.

ETHICS AND DISSEMINATION

This study was approved by the Human Research Committee/Institutional Review Board at Partners Healthcare (2019P003567). Findings will be published in peer-reviewed journals and presented at local and international conferences.

TRIAL REGISTRATION NUMBER

NCT04240301.

A novel device to prevent errors in medication dosing and dispensing

Erroneous intravenous drug administration has a high probability of causing patient morbidity or mortality during anesthesia. Anesthesiologists are cognizant of this longstanding issue, which has prompted the development of a variety of different protocols and solutions designed to ameliorate the problem and ultimately improve patient outcomes. Unfortunately, no definitive solution has been developed yet. Our invention is a medical device designed to drastically reduce, and hopefully upon further development, refinement and subsequent iterations, completely eradicate the potential for medical errors involving medication misidentification and quantitative errors in anesthetic dosing and dispensing.

Integrating a pharmacist into the perioperative setting

This paper describes the integration of a pharmacist into a perioperative environment and the ensuing quality and economic benefits. Deficiencies were identified in medication management in operating theatres (OT) at a large tertiary hospital. A perioperative pharmacist was employed for a 6-month pilot period, with permanent funding dependent on demonstration of agreed economic benefits. A multidisciplinary committee set goals, drove strategic initiatives and was accountable for delivery of outcomes. Pharmaceutical expenditure was analysed and high expenditure items targeted. Cost savings and staff satisfaction were measured at 6 months. Savings of A$63884 were achieved during the pilot period, resulting from optimised pharmaceutical unit pricing, OT medication stock on hand (imprest) review and redesigned medication management strategies. Improvements in medication management included better access to medications in the OT, rationalising available products to minimise wastage and implementation of guidelines and protocols for high-cost and high-risk medications. At 6 months, 97% of theatre staff supported continuation of the role; the project was extended with demonstrated cost savings of A$157265 at 12 months. The integration of a perioperative pharmacist resulted in cost savings and medication management improvements in the OT setting. A permanent position was funded.

Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 2

For decades, the dental profession has provided the full spectrum of anesthesia services ranging from local anesthesia to general anesthesia in the office-based ambulatory environment to alleviate pain and anxiety. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article illuminated the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medical anesthesia has implemented to manage such problems that may have utility in dentistry, and introduce a novel method for addressing these issues within dentistry known as the Dental Anesthesia Medication Safety Paradigm (DAMSP).

Surgical safety in radical cystectomy: the anesthetist's point of view-how to make a safe procedure safer

PURPOSE

The aim of this review is to present an anesthesiological overview on surgical safety for radical cystectomy implementing the cornerstones of today's rapidly evolving field of perioperative medicine.

METHODS

This is a narrative review of current perioperative medicine and surgical safety concepts for major surgery in general with special focus on radical cystectomy.

RESULTS

The tendency for perioperative care and surgical safety is to consider it a continuous proactive pathway rather than a single surgical intervention. It starts at indication for surgery and lasts until full functional recovery. Preoperative optimization leads to superior outcome by mobilizing and/or increasing physiological reserve. Multidisciplinary teamwork involving all the relevant parties from the beginning of the pathway is crucial for outcome rather than an isolated specialist approach. This fact has gained importance in times of an ageing frail population and rising health care cost. We also present our 2019 Cystectomy Enhanced Recovery Approach for optimization of perioperative care for open radical cystectomy in a high caseload center.

CONCLUSIONS

With the implementation of in itself simple but crucial steps in perioperative medicine such as multimodal prehabilitation, safety checks, better perioperative monitoring and enhanced recovery concepts, even complex surgical procedures such as radical cystectomy can be performed safer. Emphasis has to be laid on a more global view of the patients' path through the perioperative process than on the surgical procedure alone.