Medication error is a preventable cause of morbidity and mortality in medicine—and anesthesia is no exception. An Institute of Medicine (IOM) report highlights that between 44,000 and 98,000 patients die each year as a result of medical errors, a large portion of which are tragically medication related 1. Anesthesia, which requires precise technique and dosage titration, comes with a risk of medication errors, which can moderately to severely impact patient well-being during the procedure.
A recent preprint reported that the incidence of anesthesia medication errors ranged from 0.02% to 1.12%, or 1 in every 90 to 5,000 anesthetics, after a literature review 2. Among this large-scale study sample, the most reported error was a substitution error (31.6%), followed by an incorrect dose (28.4%) 2.
The timing of errors is also of interest. Medication errors tend to happen at all time points during anesthesia. Critical incidents occur most commonly in the middle of the anesthetic regimen (42%), but also can occur during induction (28%) and at the beginning of the procedure (17%) 3.
Furthermore, in contrast to the popular belief that most of the medication errors occur over the course of late-night shifts, one research study 4 surprisingly found that out of 63 drug errors, only 1 occurred at night, while 56 incidences occurred in day shifts.
Various group of drugs involved in medication errors during the practice of anesthesia have been reported by different researchers. Induction agents such as pentothal sodium, ketamine, depolarizing and non-depolarizing muscle relaxants, narcotic and sedatives, anticholinergics, and local anesthetics have all been wrongly administered to patients either due to misidentification, syringe swap, wrong labelling, or accidental exchange with another drug 5. In addition, in the context of critical care units, the involvement of inotropes, narcotics, sedatives, analgesics, potassium chloride, magnesium sulphate, and anticoagulants like heparin or anti-infective agents have been identified across a number of different studies 5. Overall, the class of medication most associated with administration errors have been found to be muscle relaxants, opioids, and antibiotics 2.
Inexperience of the anesthesiologist, nurse or student tends to be the most frequently reported contributing factor, followed by haste and communication problems 2.
In general, a certain number of elements need to be ensured while working in the operation room in order to minimize the incidence of anesthesia medication errors. First, it is best to reduce the complexity of the system as much as possible. Second, it is important to ensure a certain degree of redundancy and standardization, as basic principles in the design of a safe system. Finally, it is essential to double-check ampoules, syringes and equipment prior to beginning any procedure 5.
The management of anesthesia and critical patients has grown increasingly safe with the advent of newer, safer anesthesia drugs, high quality equipment and solid standards of monitoring. However, there is still room for improvement to minimize errors, especially given their preventable nature. In the future, additional research remains to be carried out on the incidence of medication errors during anesthesia—and the underlying reasons—which can help inform best safety practices for the field.
References
1. Kohn, L. & Coorigan, J. To err is human: Building a safer health system. Summary. To err is human: Building a safer health system (1999). DOI: 10.17226/9728
2. Murphy, B. P., Sivaratnam, G., Wong, J., Chung, F. & Abrishami, A. Medication administration errors during general anesthesia – a systematic review of prospective studies. medRxiv 2023.03.28.23287875 (2023). doi:10.1101/2023.03.28.23287875
3. Cooper, J. B., Newbower, R. S., Long, C. D. & McPeek, B. Preventable anesthesia mishaps: a study of human factors. 1978. Qual. Saf. Health Care (2002). doi:10.1136/qhc.11.3.277
4. Fasting, S. & Gisvold, S. E. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can. J. Anesth. (2000). doi:10.1007/BF03027956
5. Kothari, D., Gupta, S., Sharma, C. & Kothari, S. Medication error in anaesthesia and critical care: A cause for concern. Indian Journal of Anaesthesia (2010). doi:10.4103/0019-5049.65351