Abstract
Purpose
The Japanese Society of Anesthesiologists (JSA) has investigated critical events in several fields of anesthesiology. However, the types, frequency, and characteristics of medication errors related to anesthesia have not been investigated. By analyzing incident reports retrospectively, we investigated medication errors that occurred during anesthetic practice over the past 8 years at our institution.
Methods
Incident reports related to medication errors that occurred between May 1999 and March 2007 were analyzed retrospectively using a questionnaire published by the JSA in the “Survey of medication errors related to anesthesia”. During these 8 years, 233 incidents were reported, in a total of 27454 anesthesia cases conducted during this period. Of these incidents, 61 (26.2%) were anesthetic drug administration errors. In these 61 incidents, clerical error (e.g., erroneous prescription writing), and pre-error (defined as any incident with the potential to become an error) were excluded from the analysis. Consequently, 13 incidents were excluded and 48 incidents were analyzed.
Results
Medication errors due to overdose were the most frequent kind of error (25%), followed by substitution (23%), and omission (21%). Errors due to an incorrect route of administration were rare. The drugs most frequently involved in these errors were antibiotics and muscle relaxants. Most of the patients involved in the incidents were, fortunately, not harmed seriously. The total frequency of medication errors in the survey period was 0.175% (48 incidents in 27 454 total anesthesia cases).
Conclusion
We found that overdose, substitution, and omission were the main causes of anesthesia-related medication errors in our department.
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References
Irita K, Kawashima Y, Iwao Y, Seo N, Tsuzaki K, Morita K, Obara H. Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review (in Japanese with English Abstract). Masui (Jpn J Anesthesiol). 2004;53:320–335.
Webster CS, Merry AF, Larsson L, McGrath KA, Weller J. The frequency and nature of drug administration error during anesthesia. Anaesth Intensive Care. 2001;29:494–500.
Craig J, Wilson ME. A survey of anaesthetic misadventures. Anaesthesia. 1981;36:933–936.
Chopra V, Bovill JG, Spierdijk J. Accidents, near accidents and complications during anaesthesia. A retrospective analysis of a 10-year period in a teaching hospital. Anaesthesia. 1990;45:3–6.
Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162:1897–1903.
James RH. One thousand anaesthetic incidents: experience to date. Anaesthesia. 2003;58:856–863.
Abeysekera A, Bergman IJ, Kluger MT, Short TG. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring study database. Anaesthesia. 2005;60:220–227.
Ishikawa S, Murai K, Yokoyama K, Masuda A, Nakazawa K, Makita K. Retrospective analysis on misapplication of anesthesia-related drugs in the early stage of anesthesia training. J Anesthesia. 2006;20(Suppl):265.
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Yamamoto, M., Ishikawa, S. & Makita, K. Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital. J Anesth 22, 248–252 (2008). https://doi.org/10.1007/s00540-008-0624-4
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DOI: https://doi.org/10.1007/s00540-008-0624-4