Medication Administration Errors: How Do We Prevent Them?

By Carla Todaro, MD, from the IARS, AUA and SOCCA 2019 Annual Meetings*

The Anesthesia Patient Safety Foundation panel, Can We Eliminate Medical Errors in the Operating Room?, presented on Sunday, May 19 and moderated by APSF Board Member Richard Prielipp, MD, MBA, FCCM, University of Minnesota Medical School, reviewed one of the major causes of patient harm, medication administration errors, and tactics to prevent them.

The presenters included Karen C. Nanji, MD, MPH, Harvard Medical School and Massachusetts General Hospital, Eliot Grigg, MD, University of Washington Medicine and Seattle Children’s Hospital, Ken Catchpole, PhD, Medical University of South Carolina, and Joyce A. Wahr, MD, FAHA, University of Minnesota Medical School.

Medical errors are one of the major causes of death and injuries in thousands of patients every year and color-coded labels are not an effective method to eliminate the problem, the presenters explained.

The first speaker Dr. Nanji presented, “Perioperative Medication Errors: What is the Scope of the Problem?” She set the stage for the discussion by defining what is considered a medication error. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm in the patient. The incidence rate of medication errors in the U.S. ranged between 5-15%.

She emphasized that it is important to distinguish between the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations increase. More than one-third of the MEs led to observed ADEs, and the remaining two-thirds had the potential for harm (Anesthesiology. 2016 Jan;124(1):25-34. doi: 10.1097/ALN. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Nanji KC et al).

Dr. Grigg defined a process for reducing medication error during his presentation, “Eliminating Medication Errors using Process Design.” Simplicity in procedures allow for better safety. However, many procedures are complex, and in these cases, anesthesia safety tools can prove helpful to eliminate the error, detect the error, and detect the defect. Anesthesia safety tools also serve as a useful cognitive aid.

Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety (Paediatr Anaesth. 2017 Jun;27(6):571-580. doi: 10.1111/pan.13136. Epub 2017 Mar 28.Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.Martin LD et all).

In a presentation on “Recommended Best Practices to Keep Our Patients Safe, Expert Opinion Review,” Dr. Wahr, University of Minnesota Medical School, focused on the optimization of teamwork and performance to improve patient outcomes. How a team acts plays a major role in the final outcome.

She stressed the importance of optimizing team performance to reduce errors and selecting better tools and technologies for treatments and referenced a study she published in 2014.

Dr. Catchpole, University of Washington Medical, in his presentation, entitled, “There has to Be a Better Way,” focused the attention on the human factor and highlighted an important reflection on the work and on two possible realities for each situation – the work as imagined and the work as done.

The Anesthesia Patient Safety Foundation (APSF) recommends the introduction of prefilled syringes (PFS).

The inclusion of PFS into anesthesiology medication delivery potentially can improve system safety and workflow, according to a study by Yang et al. 

*Coverage from the panel, Can We Eliminate Medical Errors in the Operating Room?, during the IARS 2019 Annual Meeting