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Amici LD, van Pelt M, Mylott L, Langlieb M, Nanji KC. Clinical Decision Support as a Prevention Tool for Medication Errors in the Operating Room: A Retrospective Cross-Sectional Study. Anesth Analg 2024:00000539-990000000-00828. [PMID: 38870073 DOI: 10.1213/ane.0000000000007058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
BACKGROUND Medication errors in the operating room have high potential for patient harm. While electronic clinical decision support (CDS) software has been effective in preventing medication errors in many nonoperating room patient care areas, it is not yet widely used in operating rooms. The purpose of this study was to determine the percentage of self-reported intraoperative medication errors that could be prevented by CDS algorithms. METHODS In this retrospective cross-sectional study, we obtained safety reports involving medication errors documented by anesthesia clinicians between August 2020 and August 2022 at a 1046-bed tertiary care academic medical center. Reviewers classified each medication error by its stage in the medication use process, error type, presence of an adverse medication event, and its associated severity and preventability by CDS. Informational gaps were corroborated by retrospective chart review and disagreements between reviewers were resolved by consensus. The primary outcome was the percentage of errors that were preventable by CDS. Secondary outcomes were preventability by CDS stratified by medication error type and severity. RESULTS We received 127 safety reports involving 80 medication errors, and 76/80 (95%) of the errors were classified as preventable by CDS. Certain error types were more likely to be preventable by CDS than others (P < .001). The most likely error types to be preventable by CDS were wrong medication (N = 36, 100% rated as preventable), wrong dose (N = 30, 100% rated as preventable), and documentation errors (N = 3, 100% rated as preventable). The least likely error type to be preventable by CDS was inadvertent bolus (N = 3, none rated as preventable). CONCLUSIONS Ninety-five percent of self-reported medication errors in the operating room were classified as preventable by CDS. Future research should include a randomized controlled trial to assess medication error rates and types with and without the use of CDS.
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Affiliation(s)
- Lynda D Amici
- From the Northeastern University School of Nursing, Boston, Massachusetts
| | - Maria van Pelt
- From the Northeastern University School of Nursing, Boston, Massachusetts
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura Mylott
- From the Northeastern University School of Nursing, Boston, Massachusetts
| | - Marin Langlieb
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen C Nanji
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
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2
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Webster CS. Psychology in the operating theatre: the importance of colour and cognition in the redesign of clinical systems for medication safety. Br J Anaesth 2024; 132:837-839. [PMID: 38418333 DOI: 10.1016/j.bja.2024.02.003] [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: 01/14/2024] [Accepted: 02/06/2024] [Indexed: 03/01/2024] Open
Abstract
Medication errors in anaesthesia remain a leading cause of patient harm. Compared with conventional methods, use of the international colour-code standard on syringes and medication trays allows significantly more errors to be detected, and does so under conditions of cognitive load. Testing methods from experimental psychology provide important new insights for human factors research in anaesthesia and health care.
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Affiliation(s)
- Craig S Webster
- Department of Anaesthesiology and Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand.
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Jelacic S, Bowdle A, Nair BG, Nair AA, Edwards M, Boorman DJ. Lessons from aviation safety: pilot monitoring, the sterile flight deck rule, and aviation-style computerised checklists in the operating room. Br J Anaesth 2023; 131:796-801. [PMID: 37879776 DOI: 10.1016/j.bja.2023.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/26/2023] [Accepted: 08/01/2023] [Indexed: 10/27/2023] Open
Abstract
Commercial aviation practices including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists have direct applicability to anaesthesia care. The pilot monitoring performs specific tasks that complement the pilot flying who is directly controlling the aircraft flight path. The anaesthesia care team, with two providers, can be organised in a manner that is analogous to the two-pilot flight deck. However, solo providers, such as solo pilots, can emulate the pilot monitoring role by reading checklists aloud, and utilise non-anaesthesia providers to fulfil some of the functions of pilot monitoring. The sterile flight deck rule states that flight crew members should not engage in any non-essential or distracting activity during critical phases of flight. The application of the sterile flight deck rule in anaesthesia practice entails deliberately minimising distractions during critical phases of anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. Here we discuss how these commercial aviation practices may be applied in the operating room.
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Affiliation(s)
- Srdjan Jelacic
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Bowdle
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | - Akira A Nair
- Department of Computer Science, Brown University, Providence, RI, USA
| | - Mark Edwards
- Department of Cardiothoracic and ORL Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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Go KJ, Hudson C. Deep technology for the optimization of cryostorage. J Assist Reprod Genet 2023:10.1007/s10815-023-02814-y. [PMID: 37171740 PMCID: PMC10371920 DOI: 10.1007/s10815-023-02814-y] [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: 03/23/2023] [Accepted: 04/24/2023] [Indexed: 05/13/2023] Open
Abstract
Cryopreservation, for many reasons, has assumed a central role in IVF treatment cycles, which has resulted in rapidly expanding cryopreserved oocyte and embryo inventory of IVF clinics. We aspire to consider how and with what resources and tools "deep" technology can offer solutions to these cryobiology programs. "Deep tech" has been applied as a global term to encompass the most advanced application of big data analysis for the most informed construction of algorithms and most sophisticated instrument design, utilizing, when appropriate and possible, models of automation and robotics to realize all opportunities for highest efficacy, efficiency, and consistency in a process.
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Affiliation(s)
- Kathryn J Go
- Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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5
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Bowdle TA, Jelacic S, Webster CS, Merry AF. Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet. Br J Anaesth 2023; 130:14-16. [PMID: 36333160 DOI: 10.1016/j.bja.2022.09.017] [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: 08/08/2022] [Revised: 09/12/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
An error in the administration of an anaesthetic medication related to an automated dispensing cabinet resulted in a patient fatality and a highly publicised criminal prosecution of a healthcare worker, which concluded in 2022. Urgent action is required to re-engineer systems and workflows to prevent such errors. Exhortation, blame, and criminal prosecution are unlikely to advance the cause of patient safety.
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Affiliation(s)
- T Andrew Bowdle
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | - Srdjan Jelacic
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Craig S Webster
- Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Alan F Merry
- Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
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Jones-Oguh S, Elliott EM, McClung Pasqualino H, Harris K, Isserman RS. Medication safety in pediatric anesthesia: An educational review and a call to action. Paediatr Anaesth 2023; 33:17-23. [PMID: 36239463 DOI: 10.1111/pan.14576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 09/02/2022] [Accepted: 10/03/2022] [Indexed: 01/20/2023]
Abstract
Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.
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Affiliation(s)
- Sheri Jones-Oguh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth M Elliott
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heather McClung Pasqualino
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen Harris
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca S Isserman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Al-kahtani MS, Khan F, Taekeun W. Application of Internet of Things and Sensors in Healthcare. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22155738. [PMID: 35957294 PMCID: PMC9371210 DOI: 10.3390/s22155738] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 05/08/2023]
Abstract
The Internet of Things (IoT) is an innovative technology with billions of sensors in various IoT applications. Important elements used in the IoT are sensors that collect data for desired analyses. The IoT and sensors are very important in smart cities, smart agriculture, smart education, healthcare systems, and other applications. The healthcare system uses the IoT to meet global health challenges, and the newest example is COVID-19. Demand has increased during COVID-19 for healthcare to reach patients remotely and digitally at their homes. The IoT properly monitors patients using an interconnected network to overcome the issues of healthcare services. The aim of this paper is to discuss different applications, technologies, and challenges related to the healthcare system. Different databases were searched using keywords in Google Scholar, Elsevier, PubMed, ACM, ResearchGate, Scopus, Springer, etc. This paper discusses, highlights, and identifies the applications of IoT healthcare systems to provide research directions to healthcare, academia, and researchers to overcome healthcare system challenges. Hence, the IoT can be beneficial by providing better treatments using the healthcare system efficiently. In this paper, the integration of the IoT with smart technologies not only improves computation, but will also allow the IoT to be pervasive, profitable, and available anytime and anywhere. Finally, some future directions and challenges are discussed, along with useful suggestions that can assist the IoT healthcare system during COVID-19 and in a severe pandemic.
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Affiliation(s)
- Mohammad S. Al-kahtani
- Department of Computer Engineering, Prince Sattam Bin Abdul Aziz University, Al-Kharj 16273, Saudi Arabia;
| | - Faheem Khan
- Department of Computer Engineering, Gachon University, Seongnam 13120, Korea
- Correspondence: (F.K.); (W.T.)
| | - Whangbo Taekeun
- Department of Computer Engineering, Gachon University, Seongnam 13120, Korea
- Correspondence: (F.K.); (W.T.)
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Neo HJ, Sim MA, Ti LK, Ang SBL. Evaluation of the Efficiency and Safety of a Safe Label System: A Prospective Simulation Study. J Patient Saf 2022; 18:e568-e572. [PMID: 35188941 DOI: 10.1097/pts.0000000000000875] [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
OBJECTIVES Our study aims to investigate the safety and efficiency of the Codonics Safe Label System (SLS) in a prospective simulation study. METHODS Three sets of simulated experiments involving 82 anesthetists were carried out on patient simulator mannequins. The primary outcome assessed through the simulated experiments was the effectiveness of the SLS in avoiding vial swap errors. Secondary outcomes analyzed included the efficacy of the SLS in preventing syringe swap and the difference in time taken to prepare standardized drugs as compared with conventional methods. RESULTS The SLS was associated with a significant reduction in all 4 stages of vial swap error. The incidence of wrong ampoule breakage was significantly lower in the SLS group compared with the conventional group (12.1% versus 38.5%, P = 0.007). The number of staff who drew the wrong ampoule was similarly lower in the SLS group compared with the conventional group (4.9% versus 33.3%, P = 0.001). The proportions of staff who eventually wrongly labeled the loaded syringe were 0% in the SLS group and 17.9% in the conventional group (P = 0.005).Drug preparation time was longer for the SLS group than for the conventional group (239.6 ± 45.9 versus 160.3 ± 46.5 seconds, P < 0.001).There was no significant difference in the incidence of syringe swap with the use of the SLS. CONCLUSIONS The use of the SLS is effective in reducing vial swap error, but not syringe swap errors, and is associated with increased time taken for anesthetic drug preparation.
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Affiliation(s)
- Hong Jye Neo
- From the Department of Anaesthesia, National University Hospital
| | - Ming Ann Sim
- From the Department of Anaesthesia, National University Hospital
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9
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Thomas JJ, Bashqoy F, Brinton JT, Guffey P, Yaster M. Integration of the Codonics Safe Label System ® and the Omnicell XT ® Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability. Hosp Pharm 2022; 57:11-16. [PMID: 35521011 PMCID: PMC9065523 DOI: 10.1177/0018578720970464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Perioperative medication errors are recognized as a source of patient morbidity and mortality. Medication management systems with built-in scanning and label-printing functions that integrate with medication-dispensing cabinets have the potential to decrease medication administration errors by improving compliance with medication labeling. Whether these management systems will also improve periodic automatic replacement (PAR) inventory control and be accepted by users is unknown. We hypothesized that implementation of the Codonics Safe Label System®, an automated labeling system (ALS), would increase compliance with labeling guidelines and improve PAR inventory control by decreasing medication discrepancies while maintaining user acceptability in the OR. Methods: We audited a cohort of anesthesia workstations and electronic anesthesia records for 2 months to compare dispensed and administered medications and establish a discrepancy baseline. We also observed a convenience sample of syringes to evaluate labeling compliance. Post-implementation of the ALS, we repeated the audit. Finally, an anonymous survey was distributed electronically to providers to assess user acceptability. Results: Pre-implementation the average daily medication discrepancy rate was 9.7%, decreasing to 6.1% post-implementation (χ2 1 = 43.9; P < .0001). Pre-implementation 330 of 696 syringes (47.4%) were either missing a label or labeling elements. After implementation, 100% of all syringes received a label with the complete required labeling information (P < .0001). All respondents agreed or strongly agreed that the system was easy to use, accurate, met their needs, printed labels quickly, improved safety and efficiency, and was recommendable. Conclusion: The ALS significantly increased the rate of best-practice-compliant medication labeling while reducing medication inventory discrepancies. The system was highly accepted by providers.
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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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Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. AORN J 2021; 113:316-318. [PMID: 33646580 DOI: 10.1002/aorn.13328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022]
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12
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Drug Shortages in Obstetrics. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-020-00431-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Neira VM, Scheffler M, Wong D, Wang V, Hall RI. Survey of the Preparation of Cardiovascular Emergency Medications for Adult Cardiovascular Anesthesia. J Cardiothorac Vasc Anesth 2020; 35:1813-1820. [PMID: 33020001 DOI: 10.1053/j.jvca.2020.09.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/31/2020] [Accepted: 09/02/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe current practices and safety concerns regarding cardiac emergency medications in cardiac anesthesia. DESIGN An anonymous survey with multiple-choice questions. SETTINGS Online survey using Opinio platform. PARTICIPANTS Cardiac anesthesiologists from United States and Canada. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Response rate was 12% (n = 320), with 78% of respondents from the United States and 22% from Canada. The majority of the respondents were experienced (66%), academic (60%), and worked in large cardiac institutions (81%). Most cardiac emergency medications were prepared in the operating room (53.4%), followed by the pharmacy (34%) and industry (8.2%). American respondents had more medications prepared by a pharmacy (53%) versus Canadian (10%, p < 0.001). The majority (85%) considered expiration time of cardiac medications prepared in the operating room to be more than 12 hours. Familiarity with the American Society of Anesthesiologists guidelines on labeling was 58%, other medication safety guidelines 25%, and 34% were not familiar with any guidelines. The majority used color-coded labeling (95%), and a minority (11%) used bar-code systems. Most respondents (69%) agreed that lack of availability of preprepared medications could compromise patient safety. Having to prepare medications by themselves was a concern for respondents based on distractions (66%), lack of availability for emergencies (53%), labeling errors (41%), incorrect concentration (36%), sterility (33%), and stability (30%). CONCLUSION This survey found that cardiac emergency medications commonly are prepared in the operating room. The authors identified gaps in familiarity with parenteral medications safety guidelines. Most safety concerns could be addressed with the application of current medication safety guidelines.
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Affiliation(s)
- Victor M Neira
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Matthias Scheffler
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Derek Wong
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vivian Wang
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Richard I Hall
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Perioperative Medication Error Prevention. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA.
| | - Mohamed A Rehman
- Department of Anesthesiology, Johns Hopkins All Children's Hospital, 501 6th Avenue South, St Petersburg, FL 33701, USA
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Electronic Audit and Feedback With Positive Rewards Improve Anesthesia Provider Compliance With a Barcode-Based Drug Safety System. Anesth Analg 2019; 129:418-425. [DOI: 10.1213/ane.0000000000003861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jelacic S, Bowdle A, Nair BG, Togashi K, Wu C, Boorman DJ, Cain KC, Lang JD, Dellinger EP. The effects of an aviation-style computerised pre-induction anaesthesia checklist on pre-anaesthetic set-up and non-routine events. Anaesthesia 2019; 74:1138-1146. [PMID: 31155704 DOI: 10.1111/anae.14707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2019] [Indexed: 11/30/2022]
Abstract
This prospective, observational study compared the proportion of cases with missing critical pre-induction items before and after the implementation of an aviation-style computerised pre-induction anaesthesia checklist. Trained observers recorded the availability of critical pre-induction items and evaluated the characteristics of the pre-induction anaesthesia checklist performance including provider participation and distraction level, resistance to the use of the checklist and the time required for completion. Surgical cases that met the criteria for inclusion in the National Surgical Quality Improvement Program at a single academic hospital were selected for observation. A total of 853 cases were observed before and 717 after implementation of the checklist. The proportion of cases with failure to perform all pre-induction steps decreased from 10.0% to 6.4% (p = 0.012). There was also a significant decrease in the proportion of cases with non-routine events from 1.2% cases before to none after checklist implementation (p = 0.003). In 17 cases, the checklist alerted the anaesthesia provider to correct a mistake in pre-induction preparation.
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Affiliation(s)
- S Jelacic
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - A Bowdle
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - B G Nair
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - K Togashi
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - C Wu
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - D J Boorman
- Boeing Test and Evaluation, The Boeing Company, Seattle, WA, USA
| | - K C Cain
- Office of Nursing Research and Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - J D Lang
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - E P Dellinger
- Department of Surgery, University of Washington, Seattle, WA, USA
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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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Bowdle A, Jelacic S, Nair B, Jense R, Webster C, Merry A. Why we scan the barcodes of anaesthetic medications. Br J Anaesth 2019; 122:e24-e26. [DOI: 10.1016/j.bja.2018.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 11/14/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022] Open
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Infection prevention in the operating room anesthesia work area. Infect Control Hosp Epidemiol 2018; 40:1-17. [DOI: 10.1017/ice.2018.303] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Bowdle T, Jelacic S, Nair B, Togashi K, Caine K, Bussey L, Kruger C, Grieve R, Grieve D, Webster C, Merry A. Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. Br J Anaesth 2018; 121:1338-1345. [DOI: 10.1016/j.bja.2018.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 07/27/2018] [Accepted: 09/09/2018] [Indexed: 11/28/2022] Open
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Martin LD, Grigg EB, Verma S, Latham GJ, Rampersad SE, Martin LD. Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia. Paediatr Anaesth 2017; 27:571-580. [PMID: 28370645 DOI: 10.1111/pan.13136] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Lizabeth D Martin
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Eliot B Grigg
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Shilpa Verma
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Gregory J Latham
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Sally E Rampersad
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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Grigg EB, Martin LD, Ross FJ, Roesler A, Rampersad SE, Haberkern C, Low DK, Carlin K, Martin LD. Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia. Anesth Analg 2017; 124:1617-1625. [DOI: 10.1213/ane.0000000000001823] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jelacic S, Craddick K, Nair BG, Bounthavong M, Yeung K, Kusulos D, Knutson JA, Somani S, Bowdle A. Relative costs of anesthesiologist prepared, hospital pharmacy prepared and outsourced anesthesia drugs. J Clin Anesth 2017; 36:178-183. [DOI: 10.1016/j.jclinane.2016.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 09/15/2016] [Accepted: 10/27/2016] [Indexed: 11/17/2022]
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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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Khan SA, Khan S, Kothandan H. Simulator evaluation of a prototype device to reduce medication errors in anaesthesia. Anaesthesia 2016; 71:1186-90. [DOI: 10.1111/anae.13600] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 11/26/2022]
Affiliation(s)
- S. A. Khan
- Department of Anaesthesiology; Singapore General Hospital; Singapore
| | - S. Khan
- Department of Ophthalmology; KK Women's and Children's Hospital; Singapore
| | - H. Kothandan
- Department of Anaesthesiology; Singapore General Hospital; Singapore
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Wax DB, Feit JB. Accuracy of Vasopressor Documentation in Anesthesia Records. J Cardiothorac Vasc Anesth 2016; 30:656-8. [DOI: 10.1053/j.jvca.2015.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Indexed: 11/11/2022]
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34
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Jelacic S, Bowdle A. In Response. Anesth Analg 2016; 122:1222-3. [DOI: 10.1213/ane.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Craig S Webster
- Centre for Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand,
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Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology 2016; 124:25-34. [PMID: 26501385 PMCID: PMC4681677 DOI: 10.1097/aln.0000000000000904] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study is to assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, to evaluate their root causes, and to formulate targeted solutions to prevent them. METHODS In this prospective observational study, anesthesia-trained study staff (anesthesiologists/nurse anesthetists) observed randomly selected operations at a 1,046-bed tertiary care academic medical center to identify MEs and ADEs over 8 months. Retrospective chart abstraction was performed to flag events that were missed by observation. All events subsequently underwent review by two independent reviewers. Primary outcomes were the incidence of MEs and ADEs. RESULTS A total of 277 operations were observed with 3,671 medication administrations of which 193 (5.3%; 95% CI, 4.5 to 6.0) involved a ME and/or ADE. Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable. The events included 153 (79.3%) errors and 91 (47.2%) ADEs. Although 32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed ADE and an additional 70 (45.8%) had the potential for patient harm. Of the 153 errors, 99 (64.7%) were serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening. CONCLUSIONS One in 20 perioperative medication administrations included an ME and/or ADE. More than one third of the MEs led to observed ADEs, and the remaining two thirds had the potential for harm. These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative MEs.
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Affiliation(s)
- Karen C Nanji
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts (K.C.N., A.P., S.S.); Departments of Anesthesia (K.C.N.) and Medicine (D.W.B.), Harvard Medical School, Boston, Massachusetts; Partners Healthcare Systems, Inc., Wellesley, Massachusetts (K.C.N., D.L.S., D.W.B.); and Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (D.W.B.)
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Schonberger RB, Barash PG, Lagasse RS. The Surgical Care Improvement Project Antibiotic Guidelines: Should We Expect More Than Good Intentions? Anesth Analg 2015. [PMID: 26197373 DOI: 10.1213/ane.0000000000000735] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since 2006, the Surgical Care Improvement Project (SCIP) has promoted 3 perioperative antibiotic recommendations designed to reduce the incidence of surgical site infections. Despite good evidence for the efficacy of these recommendations, the efforts of SCIP have not measurably improved the rates of surgical site infections. We offer 3 arguments as to why SCIP has fallen short of expectations. We then suggest a reorientation of quality improvement efforts to focus less on reporting, and incentivizing adherence to imperfect metrics, and more on creating local and regional quality collaboratives to educate clinicians about how to improve practice. Ultimately, successful quality improvement projects are behavioral interventions that will only succeed to the degree that they motivate individual clinicians, practicing within a particular context, to do the difficult work of identifying failures and iteratively working toward excellence.
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Affiliation(s)
- Robert B Schonberger
- From the Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
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