Evidence-based strategies for preventing drug administration errors during anaesthesia

Situational Analysis of the Medication Practices in Brazilian Hospitals: A Multicenter Study

OBJECTIVE

To carry out a situational analysis of the medication practices in Brazilian hospitals through the Medication Safety Self-Assessment for Hospitals and the factors associated with better performance in the evaluation.

METHODS

This is a multicenter cross-sectional study in which the results of the application of the Medication Safety Self-Assessment for Hospitals, between 2015 and 2020, in 30 Brazilian hospitals were described. In addition, whether the institutional profile was associated with higher self-assessment scores (better performance in the evaluation) was also evaluated.

RESULTS

An average proportion of points obtained of 36.7±10.9% was identified (minimum=11.5%; maximum=59.7%), from a score ranging from 0 to 1826 points. The need to improve the use of devices for the preparation and administration of drug solutions, professional development, and patient education was highlighted. A positive association was identified between higher scores and the large or very large size of the hospitals ( P =0.026) and having accreditation certification ( P =0.007).

CONCLUSIONS

The study made it possible to identify the main weak points and opportunities for improvement of the medication system in the evaluated hospitals, bringing important reflection to national institutions.

Medication errors and mitigation strategies in obstetric anesthesia

PURPOSE OF REVIEW

Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm.

RECENT FINDINGS

Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anesthesia.

SUMMARY

In obstetric anesthesia, medication errors can include wrong medication, dose, route, time, patient, or infusion setting. These errors are often underreported, have the potential to be catastrophic, and most can be prevented. Implementation of various types of best practice cost effective mitigation strategies include recommendations to improve drug labeling, optimize storage, determine correct medication prior to administration, use non-Luer epidural and intravenous connection ports, follow patient monitoring guidelines, use smart pumps and protocols for all infusions, disseminate medication safety educational material, and optimize staffing models. Vigilance in patient care and implementation of improved patient safety measures are urgently needed to decrease harm to mothers and newborns worldwide.

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.

Comparing the Effectiveness of a Clinical Decision Support Tool in Reducing Pediatric Opioid Dose Calculation Errors: PediPain App vs. Traditional Calculators - A Simulation-Based Randomised Controlled Study

Wrong dose calculation medication errors are widespread in pediatric patients mainly due to weight-based dosing. PediPain app is a clinical decision support tool that provides weight- and age- based dosages for various analgesics. We hypothesized that the use of a clinical decision support tool, the PediPain app versus pocket calculators for calculating pain medication dosages in children reduces the incidence of wrong dosage calculations and shortens the time taken for calculations. The study was a randomised controlled trial comparing the PediPain app vs. pocket calculator for performing eight weight-based calculations for opioids and other analgesics. Participants were healthcare providers routinely administering opioids and other analgesics in their practice. The primary outcome was the incidence of wrong dose calculations. Secondary outcomes were the incidence of wrong dose calculations in simple versus complex calculations; time taken to complete calculations; the occurrence of tenfold; hundredfold errors; and wrong-key presses. A total of 140 residents, fellows and nurses were recruited between June 2018 and November 2019; 70 participants were randomized to control group (pocket calculator) and 70 to the intervention group (PediPain App). After randomization two participants assigned to PediPain group completed the simulation in the control group by mistake. Analysis was by intention-to-treat (PediPain app = 68 participants, pocket calculator = 72 participants). The overall incidence of wrong dose calculation was 178/576 (30.9%) for the control and 23/544 (4.23%) for PediPain App, P < 0·001. The risk difference was - 32.8% [-38.7%, -26.9%] for complex and - 20.5% [-26.3%, -14.8%] for simple calculations. Calculations took longer within control group (median of 69 Sects. [50, 96]) compared to PediPain app group, (median 48 Sects. [38, 63]), P < 0.001. There were no differences in other secondary outcomes. A weight-based clinical decision support tool, the PediPain app reduced the incidence of wrong doses calculation. Clinical decision support tools calculating medications may be valuable instruments for reducing medication errors, especially in the pediatric population.

Evaluating Independent Double Checks in the Pediatric Intensive Care Unit: A Human Factors Engineering Approach

OBJECTIVES

The goal of this human factors engineering-led improvement initiative was to examine whether the independent double check (IDC) during administration of high alert medications afforded improved patient safety when compared with a single check process.

METHODS

The initiative was completed at a 24-bed pediatric intensive care unit and included all patients who were on the unit and received a medication historically requiring an IDC. The total review examined 37,968 high-risk medications administrations to 4417 pediatric intensive care unit patients over a 40-month period. The following 5 measures were reviewed: (1) rates of reported medication administration events involving IDC medications; (2) hospital length of stay; (3) patient mortality; (4) nurses' favorability toward single checking; and (5) nursing time spent on administration of IDC medications.

RESULTS

The rate of reported medication administration events involving IDC medications was not significantly different across the groups (95% confidence interval, 0.02%-0.08%; P = 0.4939). The intervention also did not significantly alter mortality ( P = 0.8784) or length of stay ( P = 0.4763) even after controlling for the patient demographic variables. Nursing favorability for single checking increased from 59% of nurses in favor during the double check phase, to 94% by the end of the single check phase. Each double check took an average of 9.7 minutes, and a single check took an average of 1.94 minutes.

CONCLUSIONS

Our results suggest that performing independent double checks on high-risk medications administered in a pediatric ICU setting afforded no impact on reported medication events compared with single checking.

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.

Incidence and root causes of medication errors by anesthetists: a multicenter web-based survey from 8 teaching hospitals in Ethiopia

BAKGROUND

The operating room is a demanding and time-constrained setting, in comparison to primary care settings, where perioperative medication administration is more complicated and there is a high risk that the patient will experience a medication error. Without consulting the pharmacist or seeking assistance from other staff members, anesthesia clinicians prepare, deliver, and monitor strong anesthetic drugs. The purpose of this study was to determine the Incidence and root causes of medication errors by anesthetists in Amhara region, Ethiopia.

METHODS

A multi-center cross sectional web-based survey study was conducted from October 1 to November 30, 2022, across eight referral and teaching hospitals of Amhara region. A self-administered semi structured questionnaire was distributed using survey planet. Data analysis was conducted using SPSS version 20. Descriptive statistics were computed and binary logistic regression was used for data analysis. A p-value < 0.05 was considered statistically significant.

RESULTS

The study included 108 anesthetists in total, yielding a response rate of 42.35%. Out of 104 anesthetists, Majority of participants (82.7%) were male. During their clinical practice, more than half (64.4%) of participants experienced atleast one drug administration error. 39 (37.50%) of the respondents revealed that they experienced more medication errors while on night shifts. Anesthetists who did not always double-check their anesthetic drugs before administration had a 3.51 higher risk of developing MAEs compared to those who always double-check anesthetic drugs before administration (AOR = 3.51; 95% CI: 1.34, 9.19). Additionally, participants who administer medications that have been prepared by someone else are about five times more likely to experience MAEs than participants who prepare their own anesthetic medications prior to administration (AOR = 4.95; 95% CI: 1.54, 15.95).

CONCLUSION

The study found a considerable rate of errors in the administration of anaesthetic drugs. The failure to always double-check medications before administration and the use of drugs prepared by another anaesthetist were identified to be underlying root causes for drug administration errors.

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.

The impact of "To Err Is Human" on patient safety in anesthesiology. A bibliometric analysis of 20 years of research

Background

Patient safety gained public notoriety following the 1999 report of the Institute of Medicine: To Err is Human - Building a Safer Health System which summarized a culminated decades' worth of research that had so far been largely ignored. The aim of this study was to analyze the report's impact on patient safety research in anesthesiology.

Methods

A bibliometric analysis was performed on all anesthesiologic publications from 2000 to 2019 that referenced To Err Is Human. In bibliometric literature, references are understood to represent an author's conscious decision to express a relationship between his own manuscript and the cited document.

Results

The anesthesiologic data base contained 1.036 publications. The journal with the most references to the IOM report is Anesthesia & Analgesia. By analyzing author keywords and patterns of collaboration, changes in the patient safety debate and its core themes in anesthesiology over time could be visualized. The generic notion of "error," while initially a central topic in the scientific discourse, was subsequently replaced by terms representing a more granular, team-oriented, and educational approach. Patient safety research in anesthesia, while profiting from a certain intellectual and conceptual head start, showed a discursive shift toward more managerial, quality-management related topics as observed in the health care system as a whole.

Conclusions

Over the last 20 years, the research context expanded from the initial focus set forth by the IOM report, which ultimately led to an underrepresentation of research on critical incident reporting and systemic approaches to safety. Important collaborations with safety researchers from outside of health care dating back to the 1990's were gradually reduced, while previous research within anesthesiology was aligned with a broader, more managerial patient safety agenda.

Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm

Introduction

Significant adverse drug events (ADEs) due to anesthesia infusion pump programming errors were reported at our institution. We incorporated independent two-provider infusion pump programming verification, an evidence-supported intervention, into our anesthesia medication infusion process with a goal of reducing associated ADEs to zero in 2 years.

Methods

Using the model for improvement, we developed key drivers and interventions and utilized plan-do-study-act (PDSA) cycles. Drivers included education and training, verification process, visual aids, information technology, and safety culture. Interventions included anesthesia provider training, information dissemination, independent two-provider verification process of smart pump programming, verification documentation capability, verification compliance tracking, and visual aids. Our outcome measures were relevant ADEs and near-miss events. Process and balancing measures were the percentage of smart pump programs with independent second verification and delayed case starts due to second provider verification, respectively.

Results

During the project period, only one related grade E ADE occurred, and the root cause was not conducting an independent pump programming verification. Thirteen grade B near-miss events were prevented due to independent second verification. Second verification adherence reached 85% and was sustained, and no delayed case starts occurred.

Conclusions

With structured quality improvement methods, the process of independent two-provider verification of infusion pump programming during anesthesia can be successfully implemented, and errors in a high-volume setting reduced without negatively affecting case start times. The cultural and organizational factors we report may aid other institutions in gaining project buy-in and sustainment.

Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews

Background and aim

Improving health care quality and ensuring patient safety is impossible without addressing medical errors that adversely affect patient outcomes. Therefore, it is essential to correctly estimate the incidence rates and implement the most appropriate solutions to control and reduce medical errors. We identified such interventions.

Methods

We conducted a systematic review of systematic reviews by searching four databases (PubMed, Scopus, Ovid Medline, and Embase) until January 2021 to elicit interventions that have the potential to decrease medical errors. Two reviewers independently conducted data extraction and analyses.

Results

Seventysix systematic review papers were included in the study. We identified eight types of interventions based on medical error type classification: overall medical error, medication error, diagnostic error, patients fall, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide. Most studies focused on medication error (66%) and were conducted in hospital settings (74%).

Conclusions

Despite a plethora of suggested interventions, patient safety has not significantly improved. Therefore, policymakers need to focus more on the implementation considerations of selected interventions.

Factors Influencing Medication Errors in the Prehospital Paramedic Environment: A Mixed Method Systematic Review

INTRODUCTION

There is limited research available on safe medication management practices in EMS practice, with most evidence-based medication safety guidelines based on research in nursing, operating theatre and pharmacy settings. Prevention of errors requires recognition of contributing factors across the spectrum from the organizational level to procedural elements and patient characteristics. Evidence is inconsistent regarding the incidence of medication errors and multiple sources also state that errors are under-reported, making the true magnitude of the problem difficult to quantify. Definitions of error also vary, with the specific context of medication errors in prehospital practice yet to be established. The objective of this review is to identify the factors influencing the occurrence of medication errors by EMS personnel in the prehospital environment.

METHODS AND ANALYSIS

The review included both qualitative and quantitative research involving interventions or phenomena related to medication safety or medication error by EMS personnel in the prehospital environment. A search of multiple databases was conducted to identify studies meeting these inclusion criteria. All studies selected were assessed for methodological quality, however this was not used as a basis for exclusion. Each stage of study selection, appraisal and data extraction was conducted by two independent reviewers, with a third reviewer deciding any unresolved conflicts. The review follows a convergent integrated approach, conducting a single qualitative synthesis of qualitative and "qualitized" quantitative data.

RESULTS

56 articles were included in the review, with case reports and qualitative studies being the most frequent study types. Qualitative analysis revealed seven major themes: organizational factors (with reporting as a sub-theme), equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors (with pediatrics as a sub-theme) and cognitive factors. Both contributing factors and protective factors were identified.

DISCUSSION

The body of evidence regarding medication errors is heterogenous and limited in both quantity and quality. Multiple factors influence medication errors occurrence; knowledge of these is necessary to mitigate the risk of errors. Medication error incidence is difficult to quantify due to inconsistent measure, definitions and contexts of research conducted to date. Further research is required to quantify the prevalence of identified factors in specific practice settings.

An Analysis of Judicial Cases Concerning Analgesic-Related Medication Errors in the Republic of Korea

OBJECTIVES

Analgesic-related medication errors can be a threat to patient safety. This study aimed to identify and describe medication errors that can cause serious adverse drug events (ADEs) related to analgesic use.

METHODS

This retrospective, observational, medicolegal study analyzed closed cases concerning complications induced by medication errors involving 3 commonly used analgesics: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen (AAP). Cases closed between 1994 and 2019 that were available in the Korean Supreme Court judgment database system were included. Medication errors were categorized using a classification system (developed by our group) based on the stage of drug administration. Clinical characteristics and judgment statuses were analyzed.

RESULTS

A total of 71 cases were included in the final analysis (opioids, n = 30; NSAIDs, n = 35; AAP, n = 6). Among them, 43 claims (60.6%) resulted in payments to the plaintiffs, with a median payment of $86,607 (interquartile range, $34,554-$193,782). The severity of ADEs was high (National Association of Insurance Commissioners scale ≥6) in 88.7% (n = 63) of claims, with a total of 44 (62%) deaths. The most common types of ADEs associated with opioid, NSAID, and AAP use were respiratory depression, anaphylactic shock, and fulminant hepatitis, respectively. The most common recognized medication errors associated with opioid, NSAIDs, and AAP were inappropriate patient monitoring (n = 10; 33.3%), improper analgesic choice (n = 15; 42.9%), and inappropriate treatment after ADEs (n = 3; 50%), respectively.

CONCLUSIONS

Our findings indicate that efforts should be made to reduce medication errors related to analgesic use to prevent permanent injury and potential malpractice claims.

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.

Medical Students' Experience of Harassment and Its Impact on Quality of Life: a Scoping Review

OBJECTIVES

Medical students' experiences of harassment and its influence on quality of life were examined.

DESIGN

A set of databases were employed in this review, and using ATLAS.ti, a set of emergent themes were identified.

RESULTS

The initial search identified 4580 potential articles for review. The inclusion and exclusion criteria reduced the list to 48 articles. Two predominant emergent themes were categorised as 'Antecedents' of 'harassment' and 'Consequences' on quality of life.

CONCLUSIONS

Harassment likely has an adverse impact on quality of life, although more empirical research is required to establish more definitive links between the two variables.

Medical Students' Experience of Harassment and Its Impact on Quality of Life: a Scoping Review

OBJECTIVES

Medical students' experiences of harassment and its influence on quality of life were examined.

DESIGN

A set of databases were employed in this review, and using ATLAS.ti, a set of emergent themes were identified.

RESULTS

The initial search identified 4580 potential articles for review. The inclusion and exclusion criteria reduced the list to 48 articles. Two predominant emergent themes were categorised as 'Antecedents' of 'harassment' and 'Consequences' on quality of life.

CONCLUSIONS

Harassment likely has an adverse impact on quality of life, although more empirical research is required to establish more definitive links between the two variables.

Interventions to reduce medication errors in anesthesia: a systematic review

BACKGROUND

The objective of this study was to provide a synthesis of the interventions designed to reduce medication errors in anesthetized patients.

METHODS

We electronically searched major databases using index and free-text keywords related to anesthesia and medication errors. We included cohort studies exploring interventions to reduce anesthetic medication errors in both adult and pediatric patients. The risk of bias for each study was assessed using the Newcastle-Ottawa Scale.

RESULTS

One thousand five-hundred and fifty-eight titles or abstracts were screened, and 56 full-text studies were assessed for eligibility; eight studies were included in the final analysis. Case reports and retrospective studies were excluded. The quality of most studies (n = 6) was graded as "low". There were three categories of interventions: I) multimodal interventions (6 studies, n = 900,170 medication administrations) showed a reduction in rates of errors of 21-35% per administration and 37-41% per anesthetic; II) improved labels (1 study, n = 55,426 medication administrations) resulted in a 37% reduction in rates of errors per anesthetic; and III) the effect of education was assessed in one study and showed no effect.

CONCLUSION

Multimodal interventions and improved labelling reduce medication errors in anesthetized patients.

Exploring the pedagogical design features of the flipped classroom in undergraduate nursing education: a systematic review

Background

In recent years, technological advancement has enabled the use of blended learning approaches, including flipped classrooms. Flipped classrooms promote higher-order knowledge application – a key component of nursing education. This systematic review aims to evaluate the empirical evidence and refereed literature pertaining to the development, application and effectiveness of flipped classrooms in reference to undergraduate nursing education.

Methods

A PRISMA systematic review protocol was implemented to investigate the literature pertaining to the development, implementation and effectiveness of flipped classroom pedagogy in undergraduate nursing education. Seven databases (Scopus, PsycINFO, CINAHL, ERIC, MEDLINE, Cochrane, Web of Science) were utilised to survey the salient literature. Articles were appraised with respect to their level of evidence, the origin of study, study design, the aims/s of the study, and the key outcomes of the study. A qualitative synthesis was then conducted to summarise the study findings.

Results

The initial search identified 1263 potentially relevant articles. After comprehensively reviewing the initial catchment using several analytical phases, 27 articles were considered for the final review, most of which were conducted in the USA and South Korea. A range of research designs were applied to measure or discuss the outcomes and design features of the flipped classroom pedagogy when applied to undergraduate nursing education. The review indicated that a common operational flipped classroom model involves three key components, namely pre-classroom activities, in-classroom activities and post-classroom activities, guided by two instructional system design principles. The review predominantly identified positive learning outcomes among undergraduate nursing students, after experiencing the flipped classroom, in terms of skills, knowledge and attitudes. However, a few studies reported contrasting findings, possibly due to the incompatibility of the flipped classroom pedagogy with the traditional learning culture.

Conclusions

Current evidence in this systematic review suggests that incorporating the flipped classroom pedagogy could yield positive educational outcomes in undergraduate nursing education. There are promising pedagogical models available for adapting or developing the flipped classroom pedagogy in undergraduate nursing education.

Give Intravenous Bolus Overdose a Brake: User Experience and Perception of Safety Device

OBJECTIVES

Drugs can come in concentrated solutions that require dilution before intravenous bolus administration. Upon dilution, the syringe can contain more than the required amount of drug. The user may mistakenly administer the full contents of the syringe, resulting in an overdose. In this cross-sectional study, we evaluated user experience and perception of Syringe Brake, a dosage flow restrictor device, as part of the intravenous morphine bolus administration workflow.

METHODS

From December 2018 to January 2019, doctors and nurses working in the emergency department of 3 public tertiary hospitals in Singapore were invited to complete a paper-based 11-item 5-point Likert scale survey questionnaire after 3 months of Syringe Brake implementation.

RESULTS

Overall, 77.5% (290/374; 4.11 ± 0.83) of participants were satisfied with the use of Syringe Brake to prevent medication error. Our survey results showed that the top features of Syringe Brake were ease of setting the desired volume to be administered (86.1%; 4.21 ± 0.72), allowing the drug to be titrated safely (84.8%; 4.26 ± 0.77), and giving users the confidence to avoid overdosing the patient (82.1%; 4.21 ± 0.78). Those with hands-on experience with Syringe Brake rated significantly higher for all survey statements except on the perceived ability to prevent error arising from miscommunication (adjusted odds ratio, 1.58 [0.98-2.57]; P = 0.062).

CONCLUSIONS

Syringe Brake shows promising potential for adoption to prevent medication errors. The device serves as a constraint to prevent accidental overdose, caused by user unfamiliarity or autopilot administration.

Using Failure Mode and Effects Analysis in Blood Administration Process in Surgical Care Units: New Categories of Errors

BACKGROUND

Blood administration failures and errors have been a crucial issue in health care settings. Failure mode and effects analysis is an effective tool for the analysis of failures and errors in such lifesaving procedures. These failures or errors would lead to adverse outcomes for patients during blood administration.

OBJECTIVES

The study aimed to: use health care failure mode and effect analysis (HFMEA) for assessing potential failure modes associated with blood administration processes among nurses; develop a categorization of blood administration errors; and identify underlying reasons, proactive measures for identified failure modes, and corrective actions for identified high-risk failures.

METHODS

A cross-sectional descriptive study was conducted in surgical care units by using observation, HFMEA, and brainstorming techniques. Prioritization of detected potential failures was performed by Pareto analysis.

RESULTS

Eleven practical steps and 38 potential failure modes associated with 11 categories of errors were detected in this process. These categories of errors were newly developed in this study. In total, 17 of 38 potential failures were detected as high-risk failures that occurred during the sample-drawing, checking, preparing, administering, and monitoring steps. For cause analysis of failures and errors, proactive suggested actions were undertaken for 38 potential failure modes, and corrective actions for 17 high-risk failures.

CONCLUSION

HFMEA is an efficient and well-organized tool for identification of and reduction in high-risk failures and errors in the blood administration process among nurses without building punitive culture. This tool also helps pay attention to redesigning and standardizing the blood administration process as well as providing training and educational programs for providing knowledge.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

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.

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).

[Lean Six Sigma and anesthesia]

BACKGROUND

Demands for health services have been growing sharply. Consequently, the costs of the institutions for their operational maintenance and investments also increase. The challenge of hospital management is to achieve standards of quality and safety for patients, increasing their productivity and minimizing costs. Lean Six Sigma is a well-structured methodology that aims to eliminate waste and activities that do not add value, focused on reducing process variation, eliminating the causes of the defect, and improving performance. As a result, cost reduction, higher quality, and customer satisfaction are observed.

OBJECTIVES

To define Lean Six Sigma methodology and search references in the literature on its use in Health and specifically in Anesthesiology.

CONTENT

How often the waste of medicines, materials and time (rework), as well as the errors that happen in the day-to-day of the anesthesiologist are reported. Anesthesiologists must know the impact of their professional practice, with the purpose of making more appropriate choices, thus reducing the damage to the environment, improving overall health, and reducing costs with health care. The use of the Lean Six Sigma methodology is suggested to make the anesthesia field more sustainable, improving the processes without prejudice to the patient.

CONCLUSION

Lean Six Sigma methodology is a new business management strategy in the health area. It is perfectly inserted in the current context of quality and safety to the patient; therefore, relevant in the practice of anesthesiology.

Lean Six Sigma and anesthesia

Background

Demands for health services have been growing sharply. Consequently, the costs of the institutions for their operational maintenance and investments also increase. The challenge of hospital management is to achieve standards of quality and safety for patients, increasing their productivity and minimizing costs. Lean Six Sigma is a well-structured methodology that aims to eliminate waste and activities that do not add value, focused on reducing process variation, eliminating the causes of the defect, and improving performance. As a result, cost reduction, higher quality, and customer satisfaction are observed.

Objectives

To define Lean Six Sigma methodology and search references in the literature on its use in Health and specifically in Anesthesiology.

Content

How often the waste of medicines, materials and time (rework), as well as the errors that happen in the day-to-day of the anesthesiologist are reported. Anesthesiologists must know the impact of their professional practice, with the purpose of making more appropriate choices, thus reducing the damage to the environment, improving overall health, and reducing costs with health care. The use of the Lean Six Sigma methodology is suggested to make the anesthesia field more sustainable, improving the processes without prejudice to the patient.

Conclusion

Lean Six Sigma methodology is a new business management strategy in the health area. It is perfectly inserted in the current context of quality and safety to the patient; therefore, relevant in the practice of anesthesiology.

Simulation Training to Improve the Ability of First-Year Doctors to Assess and Manage Deteriorating Patients: a Systematic Review and Meta-analysis

Many simulation courses now exist which aim to prepare first-year doctors for the task of assessing and managing potentially deteriorating patients. Despite the substantial resources required, the degree to which participants benefit from such courses, and which aspects of the simulation training are optimal for learning, remains unclear. A systematic literature search was undertaken across seven electronic databases. Inclusion criteria were that the intervention must be a simulation of a deteriorating patient scenario that would likely be experienced by first-year doctors, and that participants being first-year doctors or in their final year of medical school. Studies reporting quantitative benefits of simulation on participants' knowledge and simulator performance underwent meta-analyses. The search returned 1444 articles, of which 48 met inclusion criteria. All studies showed a benefit of simulation training, but outcomes were largely limited to self-rated or objective tests of knowledge, or simulator performance. The meta-analysis demonstrated that simulation improved participant performance by 16% as assessed by structured observation of a simulated scenario, and participant knowledge by 7% as assessed by written assessments. A mixed-methods analysis found conflicting evidence about which aspects of simulation were optimal for learning. The results of the review indicate that simulation is an important tool to improve first-year doctors' confidence, knowledge and simulator performance with regard to assessment and management of a potentially deteriorating patient. Future research should now seek to clarify the extent to which these improvements translate into clinical practice, and which aspects of simulation are best suited to achieve this.

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.

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned

BACKGROUND

Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events. This study describes the types of anesthesia adverse events reported in VHA hospitals and their root causes and preventative actions.

METHODS

RCA reports from VHA hospitals from May 30, 2012, to May 1, 2015, were reviewed for root causes, severity of patient outcomes, and actions. These elements were coded by consensus and analyzed using descriptive statistics.

RESULTS

During the study period, 3228 RCAs were submitted, of which 292 involved an anesthesia provider. Thirty-six of these were specific to anesthesia care. We reviewed these 36 RCA reports of adverse events specific to anesthesia care. Types of event included medication errors (28%, 10), regional blocks (14%, 5), airway management (14%, 5), skin integrity or position (11%, 4), other (11%, 4), consent issues (8%, 3), equipment (8%, 3), and intravenous access and anesthesia awareness (3%, 1 each). Of the 36 anesthesia events reported, 5 (14%) were identified as being catastrophic, 10 (28%) major, 12 (34%) moderate, and 9 (26%) minor. The majority of root causes identified a need for improved standardization of processes.

CONCLUSIONS

This analysis points to the need for systemwide implementation of human factors engineering-based approaches to work toward further eliminating anesthesia-related adverse events. Such actions include standardization of processes, forcing functions, separating storage of look-alike sound-alike medications, limiting stock of high-risk medication strengths, bar coding medications, use of cognitive aids such as checklists, and high-fidelity simulation.

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

BACKGROUND

We examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.

METHODS

This study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.

RESULTS

In total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).

CONCLUSIONS

Pre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

Safe Labeling Practices to Minimize Medication Errors in Anesthesia: 5 Case Reports and Review of the Literature

Drug error is a significant hazard to patient health. Poor, incorrect, and inconsistent labeling of injectable medicines and fluids, and the devices used to deliver these, has been identified as a patient safety issue. We report 5 cases of medication error as a consequence of incorrect or inappropriate labeling and analyze their cause. Recommendations for safe and practical labeling practices in anesthesia based on a review of the literature are presented. Implementation of the recommended labeling practices can reduce the risk of medication error and contribute to the safe administration of drugs.

Anesthetic Pump Techniques Versus the Intermittent Bolus: What the Oral Surgeon Needs to Know

The most popular agents in use for office-based anesthesia are propofol, ketamine, and remifentanil, which have the desirable properties of rapid onset and short duration of action. A useful parameter in assessing these agents is the context-sensitive half-time. These anesthetic agents demonstrate relatively low, flat plots compared with older agents. For delivery of intravenous anesthetics, oral and maxillofacial surgeons have relied small incremental boluses with great success. However, relatively simple syringe infusion pumps can provide an even "smoother" anesthetic. This article familiarizes oral and maxillofacial surgeons with the advantages of infusion pumps and provides examples of their use.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.