Medication errors or adverse drug events after surgery occur in as many as one in twenty perioperative medication administrations, according to data published online in the journal Anesthesiology.
A prospective observational study of 277 surgical operations and 3,671 medication administrations found 193 cases (5.3%) involved a medication error or adverse drug event, nearly four-fifths (79.3%) of which were preventable and 68.9% of which were serious (Anesthesiology. 2015 Oct. doi:10.1097/ALN.0000000000000904).
Dr. Karen C. Nanji
Among the 51 medication errors that led to adverse reactions, nearly half were the result of inappropriate medication doses and 31.4% were due to omitted medications or failure to act, but the most common overall error type was a labeling error.
The medications most commonly associated with errors were propofol, phenylephrine, and fentanyl, and operations greater than 6 hours in duration or with 13 or more medication administrations were associated with a significantly greater risk of errors.
“Examples of technology-based interventions [to minimize perioperative MEs and/or ADEs] include bar code–assisted syringe labeling systems, point-of-care bar code–assisted anesthesia documentation systems, specific drug decision support, and alerts,” wrote the study’s lead author Dr. Karen C. Nanji of Massachusetts General Hospital in Boston, and her coauthors.
The study was supported by the Doctors Company Foundation and the National Institute of General Medical Sciences of the National Institutes of Health. One coauthor – Dr. David Bates – declared financial interests in medical decision support software, as well as funding and positions with a variety of medical technology companies.