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van Wyk R, Davids RA. Drug administration errors among anaesthesia providers in South Africa: a cross-sectional descriptive study. BMC Anesthesiol 2024; 24:270. [PMID: 39097708 PMCID: PMC11297762 DOI: 10.1186/s12871-024-02657-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 07/24/2024] [Indexed: 08/05/2024] Open
Abstract
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.
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Affiliation(s)
- René van Wyk
- Department Anaesthesiology and Critical Care, University of Stellenbosch, Parow, Cape Town, 7500, South Africa.
| | - Ryan Alroy Davids
- Department Anaesthesiology and Critical Care, University of Stellenbosch, Parow, Cape Town, 7500, South Africa
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Laher AE, Enyuma CO, Gerber L, Buchanan S, Adam A, Richards GA. Medication Errors at a Tertiary Hospital Intensive Care Unit. Cureus 2022; 13:e20374. [PMID: 35036207 PMCID: PMC8752413 DOI: 10.7759/cureus.20374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 11/07/2022] Open
Abstract
Background The intensive care unit (ICU) generates more medication prescriptions per patient day than any other unit in the hospital. The dynamics of the ICU environment, coupled with the complexity of patient pathology, increases the risk of medication errors. This study aimed to evaluate the incidence and spectrum of medication errors in an adult general ICU in Johannesburg, South Africa. Methods A retrospective chart review was conducted at a 19-bed ICU in a tertiary-level hospital in Johannesburg. Data were independently collected by two of the study investigators. The doctors’ prescription and the nurses’ administration section of patient bedside charts were scrutinized for drug prescription and administration errors. Results Of the 656 patient days studied, 3237 drugs (5.6 drugs per patient day) were prescribed. There were a total of 359 medication errors, comprising 237 (66.0%) prescription and 122 (34.0%) administration errors. The total error rate per 1000 patient days was 621.1, while the total error rate per 1000 drug prescriptions was 110.9. The most common errors were incorrect dose prescribed (n=69, 19.2%), incorrect dosing interval prescribed (n=48, 13.4%), incorrect dose administered (n=42, 11.7%) and failure to administer the prescribed drug (n=38, 10.6%). Conclusion The overall occurrence of medication errors is high but is in keeping with general international trends. Targeted interventions should be implemented to minimize the frequency of medication errors in the ICU and consequent risk to patients.
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Affiliation(s)
- Abdullah E Laher
- Emergency Medicine, University of the Witwatersrand, Johannesburg, ZAF
| | - Callistus O Enyuma
- Paediatrics, University of Calabar, Teaching Hospital, Calabar, NGA.,Emergency Medicine, University of the Witwatersrand, Johannesburg, ZAF
| | - Louis Gerber
- Emergency Medicine, University of the Witwatersrand, Johannesburg, ZAF
| | - Sean Buchanan
- Emergency Medicine, University of the Witwatersrand, Johannesburg, ZAF
| | - Ahmed Adam
- Urology, University of the Witwatersrand, Johannesburg, ZAF
| | - Guy A Richards
- Critical Care, University of the Witwatersrand, Johannesburg, ZAF
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Duffy CC, Bass GA, Duncan J, Lyons B, O'Dea A. Medication Errors in Anesthesiology: Is It Time to Train by Example? Vignettes Can Assess Error Awareness, Assessment of Harm, Disclosure, and Reporting Practices. J Patient Saf 2022; 18:16-25. [PMID: 33009184 DOI: 10.1097/pts.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | | | - James Duncan
- From the Department of Anesthesiology and Intensive Care Medicine, St James's Hospital, Dublin 8, Ireland
| | | | - Angela O'Dea
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Biro J, Rucks M, Neyens DM, Coppola S, Abernathy JH, Catchpole KR. Medication errors, critical incidents, adverse drug events, and more: examining patient safety-related terminology in anaesthesia. Br J Anaesth 2022; 128:535-545. [DOI: 10.1016/j.bja.2021.11.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 10/21/2021] [Accepted: 11/08/2021] [Indexed: 11/29/2022] Open
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Sessa F, Esposito M, Messina G, Di Mizio G, Di Nunno N, Salerno M. Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance. Healthcare (Basel) 2021; 9:870. [PMID: 34356248 PMCID: PMC8307931 DOI: 10.3390/healthcare9070870] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/27/2022] Open
Abstract
The medico-legal term "sudden death (SD)" refers to those deaths that are not preceded by significant symptoms. SD in apparently healthy individuals (newborn through to adults) represents a challenge for medical examiners, law enforcement officers, and society as a whole. This review aims to introduce a useful flowchart that should be applied in all cases of SD. Particularly, this flowchart mixes the data obtained through an up-to-date literature review and a revision of the latest version of guidelines for autopsy investigation of sudden cardiac death (SCD) in order to support medico-legal investigation. In light of this review, following the suggested flowchart step-by-step, the forensic pathologist will be able to apply all the indications of the scientific community to real cases. Moreover, it will be possible to answer all questions relative to SD, such as: death may be attributable to cardiac disease or to other causes, the nature of the cardiac disease (defining whether the mechanism was arrhythmic or mechanical), whether the condition causing SD may be inherited (with subsequent genetic counseling), the assumption of toxic or illicit drugs, traumas, and other unnatural causes.
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Affiliation(s)
- Francesco Sessa
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy;
| | - Massimiliano Esposito
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95121 Catania, Italy; (M.E.); (M.S.)
| | - Giovanni Messina
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy;
| | - Giulio Di Mizio
- Forensic Medicine, Department of Law, Economy and Sociology, Campus “S. Venuta”, Magna Graecia University, 88100 Catanzaro, Italy;
| | - Nunzio Di Nunno
- Department of History, Society and Studies on Humanity, University of Salento, 73100 Lecce, Italy;
| | - Monica Salerno
- Department of Medical, Surgical and Advanced Technologies “G.F. Ingrassia”, University of Catania, 95121 Catania, Italy; (M.E.); (M.S.)
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Gonzalez LS, Chaney MA, Wahr JA, Rebello E. What's in That Syringe? J Cardiothorac Vasc Anesth 2020; 34:2524-2531. [PMID: 32507463 DOI: 10.1053/j.jvca.2020.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Laura S Gonzalez
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
| | - Joyce A Wahr
- Department of Anesthesiology,University of Minnesota, Minneapolis, MN
| | - Elizabeth Rebello
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
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Black S, Lerman J, Banks SE, Noghrehkar D, Curia L, Mai CL, Schwengel D, Nelson CK, Foster JMT, Breneman S, Arheart KL. Drug Calculation Errors in Anesthesiology Residents and Faculty: An Analysis of Contributing Factors. Anesth Analg 2019; 128:1292-1299. [PMID: 31094802 DOI: 10.1213/ane.0000000000004013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Limited data exist regarding computational drug error rates in anesthesia residents and faculty. We investigated the frequency and magnitude of computational errors in a sample of anesthesia residents and faculty. METHODS With institutional review board approval from 7 academic institutions in the United States, a 15-question computational test was distributed during rounds. Error rates and the magnitude of the errors were analyzed according to resident versus faculty, years of practice (or residency training), duration of sleep, type of question, and institution. RESULTS A total of 371 completed the test: 209 residents and 162 faculty. Both groups committed 2 errors (median value) per test, for a mean error rate of 17.0%. Twenty percent of residents and 25% of faculty scored 100% correct answers. The error rate for postgraduate year 2 residents was less than for postgraduate year 1 (P = .012). The error rate for faculty increased with years of experience, with a weak correlation (R = 0.22; P = .007). The error rates were independent of the number of hours of sleep. The error rate for percentage-type questions was greater than for rate, dose, and ratio questions (P = .001). The error rates varied with the number of operations needed to calculate the answer (P < .001). The frequency of large errors (100-fold greater or less than the correct answer) by residents was twice that of faculty. Error rates varied among institutions ranged from 12% to 22% (P = .021). CONCLUSIONS Anesthesiology residents and faculty erred frequently on a computational test, with junior residents and faculty with more experience committing errors more frequently. Residents committed more serious errors twice as frequently as faculty.
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Affiliation(s)
- Shira Black
- From the Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Jerrold Lerman
- From the Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
- Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
- Department of Anesthesiology, John R. Oishei Children's Hospital, Buffalo, New York
| | - Shawn E Banks
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami-Miller School of Medicine, Miami, Florida
| | - Dena Noghrehkar
- Department of Anesthesiology, John R. Oishei Children's Hospital, Buffalo, New York
| | - Luciana Curia
- From the Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Christine L Mai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Deborah Schwengel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Corey K Nelson
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, California
| | - James M T Foster
- Department of Anesthesiology, State University of New York Upstate, Syracuse, New York
| | - Stephen Breneman
- From the Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Kris L Arheart
- Department of Public Health Sciences, Division of Biostatistics, University of Miami School of Medicine, Miami, Florida
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Sivia DS, Pandit JJ. Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue. Anaesthesia 2019; 74:992-1000. [DOI: 10.1111/anae.14629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2019] [Indexed: 12/16/2022]
Affiliation(s)
| | - J. J. Pandit
- Nuffield Department of Anaesthesia Oxford University Hospitals NHS Trust Oxford UK
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9
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Tuan LT. The chain effect from human resource-based clinical governance through emotional intelligence and CSR to knowledge sharing. KNOWLEDGE MANAGEMENT RESEARCH & PRACTICE 2017. [DOI: 10.1057/kmrp.2014.23] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Luu Trong Tuan
- School of Government, University of Economics Ho Chi Minh City Vietnam
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10
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Drug Errors and Protocol for Prevention among Anaesthetists in Nigeria. Anesthesiol Res Pract 2017; 2017:2045382. [PMID: 29201048 PMCID: PMC5672586 DOI: 10.1155/2017/2045382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 09/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background Drugs are often prescribed, dispensed, and administered by the same person during anaesthesia, and this may increase the risk of drug error. Objectives To assess the frequency of drug administration errors by anaesthetists, the drugs commonly involved, and the effects of such errors. Method A questionnaire-based study was carried out among participants at an annual conference of Nigerian anaesthetists. Sixty-six of the 80 participants returned the completed questionnaire. The respondents comprised 1 nurse anaesthetist, 34 resident doctors, 3 doctors with diploma in anaesthesia, and 28 consultant anaesthetists. The collated data on drug errors, the effect of such errors on patients, and formulated protocols to prevent future occurrence were subjected to descriptive analysis using Microsoft Excel. Result Drug error was reported by 71.21% and witnessed by 22.72% of the respondents. Most of the drug errors occurred during general anaesthesia (90.3%) for emergency procedures (51.61%), and muscle relaxants were most commonly involved (58.06%). Conclusion Drug errors are common among anaesthetists in Nigeria and their incidence is greater during general anaesthesia for emergency procedures, largely as a result of ampoule swaps due to similarities in ampoule design and packaging. Guidelines on their prevention should be developed by all health institutions.
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Mekonnen AB, Alhawassi TM, McLachlan AJ, Brien JAE. Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review. Drugs Real World Outcomes 2017; 5:1-24. [PMID: 29138993 PMCID: PMC5825388 DOI: 10.1007/s40801-017-0125-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Medication errors and adverse drug events are universal problems contributing to patient harm but the magnitude of these problems in Africa remains unclear. Objective The objective of this study was to systematically investigate the literature on the extent of medication errors and adverse drug events, and the factors contributing to medication errors in African hospitals. Methods We searched PubMed, MEDLINE, EMBASE, Web of Science and Global Health databases from inception to 31 August, 2017 and hand searched the reference lists of included studies. Original research studies of any design published in English that investigated adverse drug events and/or medication errors in any patient population in the hospital setting in Africa were included. Descriptive statistics including median and interquartile range were presented. Results Fifty-one studies were included; of these, 33 focused on medication errors, 15 on adverse drug events, and three studies focused on medication errors and adverse drug events. These studies were conducted in nine (of the 54) African countries. In any patient population, the median (interquartile range) percentage of patients reported to have experienced any suspected adverse drug event at hospital admission was 8.4% (4.5–20.1%), while adverse drug events causing admission were reported in 2.8% (0.7–6.4%) of patients but it was reported that a median of 43.5% (20.0–47.0%) of the adverse drug events were deemed preventable. Similarly, the median mortality rate attributed to adverse drug events was reported to be 0.1% (interquartile range 0.0–0.3%). The most commonly reported types of medication errors were prescribing errors, occurring in a median of 57.4% (interquartile range 22.8–72.8%) of all prescriptions and a median of 15.5% (interquartile range 7.5–50.6%) of the prescriptions evaluated had dosing problems. Major contributing factors for medication errors reported in these studies were individual practitioner factors (e.g. fatigue and inadequate knowledge/training) and environmental factors, such as workplace distraction and high workload. Conclusion Medication errors in the African healthcare setting are relatively common, and the impact of adverse drug events is substantial but many are preventable. This review supports the design and implementation of preventative strategies targeting the most likely contributing factors. Electronic supplementary material The online version of this article (10.1007/s40801-017-0125-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alemayehu B Mekonnen
- Faculty of Pharmacy, University of Sydney, S114, Pharmacy Building A15, Sydney, NSW, 2006, Australia.
- School of Pharmacy, University of Gondar, Gondar, Ethiopia.
| | - Tariq M Alhawassi
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Medication Safety Research Chair, King Saud University, Riyadh, Saudi Arabia
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney, S114, Pharmacy Building A15, Sydney, NSW, 2006, Australia
- Centre for Education and Research on Ageing, Concord Hospital, Sydney, NSW, Australia
| | - Jo-Anne E Brien
- Faculty of Pharmacy, University of Sydney, S114, Pharmacy Building A15, Sydney, NSW, 2006, Australia
- Faculty of Medicine, St Vincent's Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia
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Nicolescu TO. Quality trends in healthcare and their impact on anesthesiology. Rom J Anaesth Intensive Care 2017; 24:47-52. [PMID: 28913498 PMCID: PMC5555427 DOI: 10.21454/rjaic.7518.241.qty] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/27/2017] [Indexed: 11/27/2022] Open
Abstract
The new approach of a patient-centred, appropriate and timely care that was at the heart of the Institute of Medicine (IOM) initiative is changing the face of the healthcare industry in general and, in particular, of anesthesiology as a speciality. The drivers of this change are better quality and decreased healthcare costs, since despite a large expenditure for healthcare, the quality of care has not changed tremendously. Metrics have been identified, derived from the cybernetic model first described by the quality "parent". Donabedian and each of those metrics have both advantages as well as disadvantages. Ultimately the outcome measures are the ones that CMS will hold hospitals accountable for financially as well as from a safety standpoint. The culture of safety and quality as well as methodologies to improve that culture will shape the future of quality of care and improve outcomes and patient satisfaction.
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Affiliation(s)
- Teodora O. Nicolescu
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA
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Wahr J, Abernathy J, Lazarra E, Keebler J, Wall M, Lynch I, Wolfe R, Cooper R. Medication safety in the operating room: literature and expert-based recommendations. Br J Anaesth 2017; 118:32-43. [DOI: 10.1093/bja/aew379] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 01/19/2023] Open
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Hatch D, Atito-Narh E, Herschmiller E, Olufolabi A, Owen M. Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate. Int J Obstet Anesth 2016; 26:71-5. [DOI: 10.1016/j.ijoa.2015.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 11/09/2015] [Accepted: 11/24/2015] [Indexed: 11/24/2022]
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Graudins LV, Downey G, Bui T, Dooley MJ. Recommendations and Low-Technology Safety Solutions Following Neuromuscular Blocking Agent Incidents. Jt Comm J Qual Patient Saf 2016; 42:86-91. [PMID: 26803037 DOI: 10.1016/s1553-7250(16)42010-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Neuromuscular blocking agents (NMBs) are high-risk medications used to facilitate endotracheal intubation and artificial ventilation. In an incident at a metropolitan tertiary referral and teaching public hospital in Australia, a neurosurgical patient became unresponsive at the start of surgery. It was determined that cisatracurium was administered in error in place of midazolam; the patient was ventilated and the emergency surgery continued. Two additional non-operating room (OR) drug-swap cases involving cisatracurium were reported within 12 months of this event, resulting in a comprehensive review of NMB safety. METHODS A root cause analysis (RCA) resulted in multiple interventions to decrease the risk of selection and administration errors: (1) review of NMB packaging and introduction of in-house NMB labeling by pharmacy procurement staff before distribution; (2) implementation of a medication administration in anesthetics guideline with ongoing education; (3) audit of storage with removal of NMBs; (4) review of new products by medication safety pharmacists and a senior anesthetist before distribution; and (5) use of red-barrel syringes for administering NMBs was expanded to all areas using NMBs to minimize syringe-swap incidents. RESULTS In the four years since full implementation of interventions, there have been no reports of cisatracurum selection errors. An incident of atracurium administration resulted in further recommendations for review of OR cart storage. Ongoing monitoring via medication safety walkrounds, by OR staff, by the perioperative pharmacist, and through the hospital's medication incident monitoring system has not detected any further NMB incidents. CONCLUSIONS Technological solutions have been shown to decrease the risk of NMB errors, yet multifaceted low-technology solutions may be an effective, cheaper alternative.
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Flannery AH, Parli SE. Medication Errors in Cardiopulmonary Arrest and Code-Related Situations. Am J Crit Care 2016; 25:12-20. [PMID: 26724288 DOI: 10.4037/ajcc2016190] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PubMed/MEDLINE (1966-November 2014) was searched to identify relevant published studies on the overall frequency, types, and examples of medication errors during medical emergencies involving cardiopulmonary resuscitation and related situations, and the breakdown by type of error. The overall frequency of medication errors during medical emergencies, specifically situations related to resuscitation, is highly variable. Medication errors during such emergencies, particularly cardiopulmonary resuscitation and surrounding events, are not well characterized in the literature but may be more frequent than previously thought. Depending on whether research methods included database mining, simulation, or prospective observation of clinical practice, reported occurrence of medication errors during cardiopulmonary resuscitation and surrounding events has ranged from less than 1% to 50%. Because of the chaos of the resuscitation environment, errors in prescribing, dosing, preparing, labeling, and administering drugs are prone to occur. System-based strategies, such as infusion pump policies and code cart management, as well as personal strategies exist to minimize medication errors during emergency situations.
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Affiliation(s)
- Alexander H. Flannery
- Alexander H. Flannery is a critical care pharmacist, medical intensive care unit/pulmonary, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Sara E. Parli is a critical care pharmacist, trauma/acute care surgery, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy
| | - Sara E. Parli
- Alexander H. Flannery is a critical care pharmacist, medical intensive care unit/pulmonary, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky. Sara E. Parli is a critical care pharmacist, trauma/acute care surgery, University of Kentucky HealthCare, and an adjunct assistant professor, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy
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Perfil de erros de administração de medicamentos em anestesia entre anestesiologistas catarinenses. Braz J Anesthesiol 2016; 66:105-10. [DOI: 10.1016/j.bjan.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 06/26/2014] [Indexed: 11/21/2022] Open
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Erdmann TR, Garcia JHS, Loureiro ML, Monteiro MP, Brunharo GM. Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina. Braz J Anesthesiol 2015; 66:105-10. [PMID: 26768939 DOI: 10.1016/j.bjane.2014.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 06/26/2014] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Anesthesiology is the only medical specialty that prescribes, dilutes, and administers drugs without conferral by another professional. Adding to the high frequency of drug administration, a propitious scenario to errors is created. OBJECTIVE Access the prevalence of drug administration errors during anesthesia among anesthesiologists from Santa Catarina, the circumstances in which they occurred, and possible associated factors. MATERIALS AND METHODS An electronic questionnaire was sent to all anesthesiologists from Sociedade de Anestesiologia do Estado de Santa Catarina, with direct or multiple choice questions on responder demographics and anesthesia practice profile; prevalence of errors, type and consequence of error; and factors that may have contributed to the errors. RESULTS Of the respondents, 91.8% reported they had committed administration errors, adding the total error of 274 and mean of 4.7 (6.9) errors per respondent. The most common error was replacement (68.4%), followed by dose error (49.1%), and omission (35%). Only 7% of respondents reported neuraxial administration error. Regarding circumstances of errors, they mainly occurred in the morning (32.7%), in anesthesia maintenance (49%), with 47.8% without harm to the patient and 1.75% with the highest morbidity and irreversible damage, and 87.3% of cases with immediate identification. As for possible contributing factors, the most frequent were distraction and fatigue (64.9%) and misreading of labels, ampoules, or syringes (54.4%). CONCLUSION Most respondents committed more than one error in anesthesia administration, mainly justified as a distraction or fatigue, and of low gravity.
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McLennan SR, Engel-Glatter S, Meyer AH, Schwappach DLB, Scheidegger DH, Elger BS. The impact of medical errors on Swiss anaesthesiologists: a cross-sectional survey. Acta Anaesthesiol Scand 2015; 59:990-8. [PMID: 25952281 DOI: 10.1111/aas.12517] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 02/26/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinicians involved in medical errors can experience significant distress. This study aims to examine (1) how medical errors impact anaesthesiologists in key work and life domains; (2) anaesthesiologists' attitudes regarding support after errors; (3) and which anaesthesiologists are most affected by errors. METHODS This study is a mailed cross-sectional survey completed by 281 of the 542 clinically active anaesthesiologists (52% response rate) working at Switzerland's five university hospitals between July 2012 and April 2013. RESULTS Respondents reported that errors had negatively affected anxiety about future errors (51%), confidence in their ability as a doctor (45%), ability to sleep (36%), job satisfaction (32%), and professional reputation (9%). Respondents' lives were more likely to be affected as error severity increased. Ninety per cent of respondents disagreed that hospitals adequately support them in coping with the stress associated with medical errors. Nearly all of the respondents (92%) reported being interested in psychological counselling after a serious error, but many identified barriers to seeking counselling. However, there were significant differences between departments regarding error-related stress levels and attitudes about error-related support. Respondents were more likely to experience certain distress if they were female, older, had previously been involved in a serious error, and were dissatisfied with their last error disclosure. CONCLUSION Medical errors, even minor errors and near misses, can have a serious effect on clinicians. Health-care organisations need to do more to support clinicians in coping with the stress associated with medical errors.
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Affiliation(s)
- S. R. McLennan
- Institute for Biomedical Ethics; Universität Basel; Basel Switzerland
- Centre for Health Policy, School of Population and Global Health; University of Melbourne; Melbourne Victoria Australia
| | - S. Engel-Glatter
- Institute for Biomedical Ethics; Universität Basel; Basel Switzerland
| | - A. H. Meyer
- Department of Psychology; Division of Clinical Psychology and Epidemiology; Universität Basel; Basel Switzerland
| | - D. L. B. Schwappach
- Swiss Patient Safety Foundation; Zurich Switzerland
- Institute of Social and Preventive Medicine; Universität Bern; Bern Switzerland
| | - D. H. Scheidegger
- Prof. emer. Anesthesia and Intensive Care; Universität Basel; Basel Switzerland
| | - B. S. Elger
- Institute for Biomedical Ethics; Universität Basel; Basel Switzerland
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Affiliation(s)
- Priyanka Sethi
- Department of Anesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ankita Verma
- Department of Anesthesia and Critical Care, Dr. SN Medical College, Jodhpur, Rajasthan, India
| | - Avneesh Khare
- Department of Anesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Symons VC, McMurray A. Factors influencing nurses to withhold surgical patients’ oral medications pre- and postoperatively. Collegian 2014; 21:267-74. [DOI: 10.1016/j.colegn.2013.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Shaw RE, Litman RS. Medication Safety in the Operating Room: A Survey of Preparation Methods and Drug Concentration Consistencies in Children’s Hospitals in the United States. Jt Comm J Qual Patient Saf 2014; 40:471-5. [DOI: 10.1016/s1553-7250(14)40060-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Affiliation(s)
- Chitra Juwarkar
- Department of Anesthesiology, Goa Medical College, Bambolim, Goa, India
| | - Pabitra Ghoshal
- Department of Anesthesiology, Goa Medical College, Bambolim, Goa, India
| | - Annie John
- Department of Anesthesiology, Goa Medical College, Bambolim, Goa, India
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Anesthesiologists' ability in calculating weight-based concentrations for pediatric drug infusions: an observational study. J Clin Anesth 2014; 26:276-80. [DOI: 10.1016/j.jclinane.2013.11.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 11/16/2013] [Accepted: 11/22/2013] [Indexed: 11/19/2022]
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Ogboli-Nwasor E. Medication errors in anaesthetic practice: a report of two cases and review of the literature. Afr Health Sci 2013; 13:845-9. [PMID: 24250330 DOI: 10.4314/ahs.v13i3.46] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Mistakes in the identification and administration of drugs may be fatal. This is especially so in the practice of anaesthesia. This is a report of 2 cases of near fatality due to mistakes in drug administration from look-alike medications. OBJECTIVE To highlight the significance of medication errors in our practice and to discuss the best methods of prevention. METHOD A report of two cases of errors in the administration of drugs during the conduct of anaesthesia. The subsequent management of the cases is presented, and the findings from the literature are discussed. RESULT In case 1, an adult male presented for herniorrhaphy and after induction with propofol 1mg/kg intravenously, Pancuronium bromide injection 4 mg was administered intravenously, in the place of suxamethonium chloride injection. In case 2, For induction of anaesthesia, 100mg of thiopentone sodium was administered in place of 25mg of the same drug because Thiopentone 1 gm vial was mistaken for Thiopentone 500 mg vial in a 2 year old girl. In both cases, the errors were detected early and there were no adverse sequelae. CONCLUSION Medication errors are a potential source of iatrogenic harm to patients undergoing anaesthesia. Strict adherence to principles as well as constant vigilance would minimize this problem.
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Affiliation(s)
- E Ogboli-Nwasor
- Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
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Stucki C, Sautter AM, Wolff A, Fleury-Souverain S, Bonnabry P. Accuracy of preparation of i.v. medication syringes for anesthesiology. Am J Health Syst Pharm 2013; 70:137-42. [DOI: 10.2146/ajhp110654] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Cyril Stucki
- Pharmacy Cytotoxic Unit, Pharmacy, Geneva University Hospitals, and Ph.D. student, School of Pharmaceutical Sciences, University of Geneva and University of Lausanne, Geneva, Switzerland
| | | | - Adriana Wolff
- Service of Anaesthesiology, Geneva University Hospitals
| | | | - Pascal Bonnabry
- Geneva University Hospitals, and Associate Professor, School of Pharmaceutical Sciences, University of Geneva and University of Lausanne
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Ashkenazi M, Bijaoui E, Blumer S, Gordon M. Common mistakes, negligence and legal offences in paediatric dentistry: a self-report. Eur Arch Paediatr Dent 2012; 12:188-94. [DOI: 10.1007/bf03262805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Review article: Improving drug safety for patients undergoing anesthesia and surgery. Can J Anaesth 2012; 60:127-35. [DOI: 10.1007/s12630-012-9853-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 11/27/2012] [Indexed: 10/27/2022] Open
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Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit. Intensive Care Med 2012; 38:1858-67. [PMID: 22885650 DOI: 10.1007/s00134-012-2660-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 07/11/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors. METHODS A prospective, non-blinded, observational study was undertaken in a 12-bed tertiary PICU over a period of 134 weeks. Baseline prescribing error data were collected on weekdays for all patients for a period of 32 weeks, following which the ZTP policy was introduced. Daily error feedback was introduced after a further 12 months. Errors were sub-classified as 'clinical', 'non-clinical' and 'infusion prescription' errors and the effects of interventions considered separately. RESULTS The baseline combined prescribing error rate was 892 (95 % confidence interval (CI) 765-1,019) errors per 1,000 PICU occupied bed days (OBDs), comprising 25.6 % clinical, 44 % non-clinical and 30.4 % infusion prescription errors. The combined interventions of ZTP plus daily error feedback were associated with a reduction in the combined prescribing error rate to 447 (95 % CI 389-504) errors per 1,000 OBDs (p < 0.0001), an absolute risk reduction of 44.5 % (95 % CI 40.8-48.0 %). Introduction of the ZTP policy was associated with a significant decrease in clinical and infusion prescription errors, while the introduction of daily error feedback was associated with a significant reduction in non-clinical prescribing errors. CONCLUSION The combined interventions of ZTP and daily error feedback were associated with a significant reduction in prescribing errors in the PICU, in line with Department of Health requirements of a 40 % reduction within 5 years.
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Standardised drug labelling in intensive care: results of an international survey among ESICM members. Intensive Care Med 2012; 38:1298-305. [PMID: 22527084 DOI: 10.1007/s00134-012-2569-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Standardised coloured drug labels may increase patient safety in the intensive care unit (ICU). The rates of adherence to standardised drug syringe labelling (DSL) in European and non-European ICUs, and the standards applied are not known. The aim of this survey among ESICM members was to assess if and what standardised drug syringe labelling is used, if the standards for drug syringe labelling are similar internationally and if intensivists expect that standardised DSL should be delivered by the pharmaceutical industry. METHODS A structured, web-based, anonymised survey on standardised DSL, performed among ESICM members (March-May 2011; Clinicaltrials.gov NCT01232088). Descriptive data analysis was performed and Fisher's exact test was applied where applicable. RESULTS Four hundred eighty-two submissions were analysed (20 % non-European). Thirty-five percent of the respondents reported that standardised drug labelling was used hospital-wide, and 39 % reported that standardised DSL was used in their ICU (Europe: Northern 53 %, Western 52 %, Eastern 17 %, Southern 22 %). The International Organization of Standardization (ISO) 26825 norm in its original form was used by 30 %, an adapted version by 19 % and local versions by 45 %; 6 % used labels that were included in the drug's packaging. Eighty percent wished that the pharmaceutical industry supplied ISO 26825 norm labelling together with the drugs. CONCLUSIONS Standardised DSL is not widely applied in European and non-European ICUs and mostly does not adhere strictly to the ISO norm. The frequency and quality of DSL differs to a great extent among European regions. This leaves much room for improvement.
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Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth 2012; 59:562-70. [DOI: 10.1007/s12630-012-9696-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 03/13/2012] [Indexed: 10/28/2022] Open
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Mansour M, James V, Edgley A. Investigating the safety of medication administration in adult critical care settings. Nurs Crit Care 2012; 17:189-97. [PMID: 22698161 DOI: 10.1111/j.1478-5153.2012.00500.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high-risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings. PURPOSE This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. SEARCH STRATEGIES (INCLUSION AND EXCLUSION CRITERIA): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer-reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant. CONCLUSION The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.
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Affiliation(s)
- Mansour Mansour
- Acute Care Department, Faculty of Health and Social Care, Anglia Ruskin University, Chelmsford, Essex, UK.
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[Second wave of the French drug harmonisation programme to prevent medication errors: overall appreciation of healthcare professionals]. ACTA ACUST UNITED AC 2011; 31:15-22. [PMID: 22154447 DOI: 10.1016/j.annfar.2011.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 09/05/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Medication errors are a significant cause of severe healthcare-associated complications. In December 2006, the French Health Products Agency (Afssaps) has issued a protocol to harmonise labeling of injectable drugs vials. In 2007, a first change was launched for four drugs and was followed in 2008-2009 by a second wave concerning 42 active drugs. METHODS The present study describes how healthcare professionals have perceived this change and their overall appreciation of the drug harmonisation programme. A survey using an electronic questionnaire was distributed to medical and non-medical professionals in anaesthesia and intensive care and pharmacists in a representative sample of 200 French hospitals. RESULTS The harmonisation procedure was felt as being overall satisfactory by 53% of professionals who had responded but it was recognised that the new procedure is associated with improved readability and understanding of drug dosage. The use of colour coding was also well accepted by the personnel of clinical units. Respondents expressed significant criticisms regarding both the communication plan and the way the plan was implemented locally in hospitals. Old and new labeling coexisted in 66% of responding hospitals and many respondents described being aware of errors or near-misses that were considered related to the transition. For many important topics, pharmacists had views that were significantly different from clinicians. CONCLUSION This national survey describing the perception of healthcare professionals regarding the new harmonisation procedure for injectable drugs highlighted some progress but also a number of deficiencies, notably regarding communication and implementation of the change in clinical units. This survey will be used by the French Health Products Agency to improve future steps of the long-lasting campaign against medication errors.
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Mohammad A, Zafar N, Feerick A. Cardiac arrest in intensive care unit: Case report and future recommendations. Saudi J Anaesth 2011; 4:31-4. [PMID: 20668565 PMCID: PMC2900051 DOI: 10.4103/1658-354x.62613] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Initiation of hemofiltration in a patient in septic shock can cause hemodynamic compromise potentially leading to cardiac arrest. We propose that the standard '4Hs and 4Ts' approach to the differential diagnosis of a cardiac arrest should be supplemented in critically ill patients with anaphylaxis and human and technical errors involving drug administration (the 5th H and T). To illustrate the point, we report a case where norepinephrine infused through a central venous catheter (CVC) was being removed by the central venovenous hemofiltration (CVVH) catheter causing the hemodynamic instability. CVVH has this potential of interfering with the systemic availability of drugs infused via a closely located CVC.
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Affiliation(s)
- A Mohammad
- Specialist Registrar in Anesthesia, Nottingham City Hospital, Nottingham, United Kingdom
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Liu W, Manias E, Gerdtz M. Understanding medication safety in healthcare settings: a critical review of conceptual models. Nurs Inq 2011; 18:290-302. [PMID: 22050615 DOI: 10.1111/j.1440-1800.2011.00541.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Understanding medication safety in healthcare settings: a critical review of conceptual models Communication can impact on the way in which medications are managed across healthcare settings. Organisational cultures and the environmental context provide an added complexity to how communication occurs in practice. The aims of this paper are: to examine six models relating to medication safety in various hospital and community settings, to consider the strengths and limitations of each model and to explore their applications to medication safety practices. The models examined for their ability to address the complexity of the medication communication process include causal models, such as the Human Error Model and the System Analysis to Clinical Incidents Model, and exploratory models, such as the Shared Decision-Making Model, the Medication Decision-Making and Management Model, the Partnership Model and the Medication Communication Model. The Medication Communication Model provides particular insights into possible interactions between aspects that influence medication safety practices. The implications of all six models for healthcare practice and future research are also discussed.
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Affiliation(s)
- Wei Liu
- The University of Melbourne, Carlton, Vic., Australia
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Hobai IA, Gauran C, Chitilian HV, Ehrenfeld JM, Levinson J, Sandberg WS. The management and outcome of documented intraoperative heart rate-related electrocardiographic changes. J Cardiothorac Vasc Anesth 2011; 25:791-8. [PMID: 21724417 DOI: 10.1053/j.jvca.2011.03.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The authors analyzed surgical cases in which electrocardiographic (ECG) signs of cardiac ischemia were noted to be precipitated by increases in heart rate (ie, heart rate-related ECG changes [REC]). The authors aimed to find REC incidence, specificity for coronary artery disease (CAD), and the outcome associated with different management strategies. DESIGN A retrospective review. SETTING A university hospital, tertiary care. PARTICIPANTS Patients undergoing surgery under anesthesia. INTERVENTIONS A chart review. MEASUREMENTS The authors searched 158,252 anesthesia electronic records for comments noting REC (ie, ST-segment or T-wave changes). After excluding cases with potentially confounding conditions (eg, hypotension, hyperkalemia, and so on), 26 cases were analyzed. RESULTS REC commonly was precipitated by anesthesia-related events (ie, intubation, extubation, and treatment of bradycardia). In 24 cases, REC was managed by prompt heart rate reduction using β-blocker agents, opioids, and/or cardioversion in the addition to the removal of stimulus. Only 1 case had a copy of the ECG printed. Two cases were aborted, 1 was shortened and 23 proceeded without change. Postoperative troponin T levels were checked, and cardiology consultation was obtained in selected cases and led to further cardiac evaluation in 6 cases. Postoperative myocardial infarction developed in only 1 patient in whom the ECG changes were allowed to persist throughout the case. CONCLUSIONS This incidence of reported REC was much lower than the previously reported incidence of ischemia-related ECG changes, suggesting that the largest proportion of events go unnoticed. In many patients, subsequent cardiology workup did not confirm the existence of clinically significant CAD.
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Affiliation(s)
- Ion A Hobai
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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Abstract
This review will attempt to put the various systems that allow clinicians to assess errors, omissions, or avoidable incidents into context and where possible, look for areas that deserve more or less attention and resource specifically for those of us who practice pediatric anesthesia. Different approaches will be contrasted with respect to their outputs in terms of positive impact on the practice of anesthesia. These approaches include audits by governmental organizations, national representative bodies, specialist societies, commissioned boards of inquiry, medicolegal sources, and police force investigations. Implementation strategies are considered alongside the reports as the reports cannot be considered end points themselves. Specific areas where pediatric anesthetics has failed to address recurring risk through any currently available tools will be highlighted.
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Affiliation(s)
- Graham Bell
- Department of Anaesthetics, Royal Hospital for Sick Children, Glasgow, UK.
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How do we know that we are doing a good job – Can we measure the quality of our work? Best Pract Res Clin Anaesthesiol 2011; 25:109-22. [DOI: 10.1016/j.bpa.2011.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 02/23/2011] [Accepted: 02/23/2011] [Indexed: 11/19/2022]
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Gómez-Arnau JI, Otero MJ, Bartolomé A, Errando CL, Amal D, Moreno AM, Puebla G, Marzal JM, Santa Ursula JA, González R, Pérez M, García del Valle S, González A, Domínguez-Gil A. [Labeling of injectable drugs used in anesthesia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:375-383. [PMID: 21797088 DOI: 10.1016/s0034-9356(11)70087-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- J I Gómez-Arnau
- Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid.
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Abstract
Drug administration errors are a major cause of morbidity and mortality in hospitalized patients. These errors result in major harm and incur dramatic costs to the delivery of health care. This article highlights this problem, especially as it deals with patients in the perioperative setting.
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Affiliation(s)
- George M Hanna
- Department of Anesthesia, Critical Care and Pain Medicine, 55 Fruit Street, Boston, MA 02114, USA
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Say what you mean to say: improving patient handoffs in the operating room and beyond. Simul Healthc 2011; 5:248-53. [PMID: 21330805 DOI: 10.1097/sih.0b013e3181e3f234] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Perioperative Pharmacology: Antibiotic Administration. AORN J 2011; 93:340-8; quiz 349-51. [DOI: 10.1016/j.aorn.2010.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 08/17/2010] [Indexed: 11/21/2022]
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Use of a new task-relevant test to assess the effects of shift work and drug labelling formats on anesthesia trainees’ drug recognition and confirmation. Can J Anaesth 2010; 58:38-47. [DOI: 10.1007/s12630-010-9404-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Accepted: 10/12/2010] [Indexed: 10/18/2022] Open
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Abstract
Formal and informal fallacies refer to errors in reasoning or logic, which result from invalid arguments. Formal fallacies refer to arguments that have an invalid structure or ‘form’, while informal fallacies refer to arguments that have incorrect or irrelevant premises. There are many formal and informal fallacies that could theoretically occur in anaesthesia practice or in the appraisal of anaesthesia research. This paper describes several such potential fallacies. It is possible that a greater awareness, recognition and discussion of these logic-based errors will lead to improved patient safety and more informed appraisal of clinical research.
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Affiliation(s)
- N. M. Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- M.B., B.S., F.A.N.Z.C.A., M.D., Clinical Professor, School of Medicine and Pharmacology, University of Western Australia and Head, Department of Anaesthesia, Sir Charles Gairdner Hospital
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Went K, Antoniewicz P, Corner DA, Dailly S, Gregor P, Joss J, McIntyre FB, McLeod S, Ricketts IW, Shearer AJ. Reducing prescribing errors: can a well-designed electronic system help? J Eval Clin Pract 2010; 16:556-9. [PMID: 20102435 DOI: 10.1111/j.1365-2753.2009.01159.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES In this study, the aim was to investigate if an electronic prescribing system designed specifically to reduce errors would lead to fewer errors in prescribing medicines in a secondary care setting. METHOD The electronic system was compared with paper prescription charts on 16 intensive care patients to assess any change in the number of prescribing errors. RESULTS The overall level of compliance with nationally accepted standards was significantly higher with the electronic system (91.67%) compared with the paper system (46.73%). Electronically generated prescriptions were found to contain significantly fewer deviations (28 in 329 prescriptions, 8.5%) than the written prescriptions (208 in 408 prescriptions, 51%). CONCLUSION Taking an interdisciplinary approach to work on the creation of a system designed to minimize the risk of error has resulted in a favoured system that significantly reduces the number of errors made.
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Affiliation(s)
- Kathryn Went
- School of Computing, University of Dundee, Dundee, UK.
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Kothari D, Gupta S, Sharma C, Kothari S. Medication error in anaesthesia and critical care: A cause for concern. Indian J Anaesth 2010; 54:187-92. [PMID: 20885862 PMCID: PMC2933474 DOI: 10.4103/0019-5049.65351] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.
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Affiliation(s)
- Dilip Kothari
- Department of Anaesthesiology, G. R. Medical College, Gwalior, Madhya Pradesh, India
| | - Suman Gupta
- Department of Anaesthesiology, G. R. Medical College, Gwalior, Madhya Pradesh, India
| | - Chetan Sharma
- Department of Anaesthesiology, G. R. Medical College, Gwalior, Madhya Pradesh, India
| | - Saroj Kothari
- Pharmacology, G. R. Medical College, Gwalior, Madhya Pradesh, India
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Chiang HY, Lin SY, Hsu SC, Ma SC. Factors determining hospital nurses' failures in reporting medication errors in Taiwan. Nurs Outlook 2010; 58:17-25. [PMID: 20113751 DOI: 10.1016/j.outlook.2009.06.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Indexed: 11/17/2022]
Abstract
This study examined factors that were determined to lead to failures in reporting medication administration errors (MAEs) for 838 frontline nurses from 5 teaching hospitals in Taiwan. The underreporting of these errors is a challenge to medication safety improvement. Results showed that 337 (47%) participating nurses had failed to report self- or coworker-MAEs and 376 nurses (52.4%) had not failed to report. The strongest predictors of the failure were experience of making MAEs, differences in attitude toward reporting self- and coworker-MAEs, and perceived MAE reporting rate in current work. The reporting barriers of fear, perception of nursing quality, and perception of nursing professional development significantly contributed to failure to report. Educating nurses about the goals of incident reporting systems and using MAE data to enhance patient safety culture is recommended. Further, hospital administrators should provide information and encouragement to nurses whose responsibility it is to report MAEs.
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Affiliation(s)
- Hui-Ying Chiang
- Nursing Department, Chi Mei Medical Center, Yung Kang City, Tainan, Taiwan
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Standardizing anesthesia medication drawers using human factors and quality assurance methods. Can J Anaesth 2010; 57:490-9. [DOI: 10.1007/s12630-010-9274-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 01/12/2010] [Indexed: 10/19/2022] Open
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