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Perioperative Drug Errors & ADEs

Perioperative Drug Errors & ADEs

While much attention has been given to errors in various areas of medicine, few studies have explored perioperative medication error rates. “Much of the available research on perioperative medication errors comes from self-reported data, which can underrepresent true error rates,” explains Karen C. Nanji, MD, MPH. She adds that there can be less double-checking during surgery than on inpatient wards because of the rapidity with which a patient’s condition can change in the operating room. To address this issue from a different perspective, Dr. Nanji and colleagues at Massachusetts General Hospital had an observational study published in Anesthesiology that assessed rates of perioperative medication errors and adverse drug events (ADEs) as percentages of medication administrations. For the study, four anesthesia-trained clinician-researchers observed 225 anesthesia providers during 277 randomly selected operations over 8 months. The observers documented every medication administration, potential medication error, and ADE. An expert adjudication panel reviewed all observer notes as well as chart data from the anesthesia information management system for all potential medication errors and ADEs. This was done in order to determine whether or not they constituted true medication errors or ADEs. The investigators then classified events by severity and whether or not they could have been prevented. Important Findings Overall, 124 of the 277 observed operations included at least one medication error or adverse drug event. “One in 20 perioperative medication administrations included a medication error and/or an ADE,” says Dr. Nanji. In addition, almost 80% of the medication errors and ADEs were determined to have been preventable. Although about 21% of the errors had little potential for harm, one-third led to an...
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