[Medication errors in anesthesia: unacceptable or unavoidable?]

Area of Science:

• Patient Safety
• Healthcare Systems
• Anesthesiology

Background:

• Medication errors are a significant cause of patient morbidity and mortality, leading to adverse effects and increased institutional costs.
• Preventing medication errors is a priority due to rising patient awareness and medical claims.
• Individual efforts are insufficient; systemic changes and protocol updates are necessary to curb medication errors.

Purpose of the Study:

• To highlight the critical need for preventing medication errors in healthcare settings.
• To discuss common causes and contexts of medication errors, particularly perioperatively and in the ICU.
• To advocate for a shift from blame to a 'just culture' and explore innovative solutions for error prevention.

Main Methods:

• Review of common medication error types, including wrong medication, overdose, incorrect route, underdosing, and omission.
• Identification of error-prone periods such as perioperative care and intensive care unit (ICU) stays.
• Discussion of contributing factors, encompassing human and system errors.
• Introduction of novel systems like VEINROM as a preventative measure.

Main Results:

• Medication errors can lead to severe adverse events, including death, and are often irreversible.
• Common errors include wrong medication, overdose, incorrect administration routes, underdosing, and omissions, frequently occurring during perioperative periods and in ICUs.
• Both human factors and systemic issues contribute to medication errors during preparation, administration, and record-keeping.

Conclusions:

• Preventing medication errors requires a multi-faceted approach, emphasizing systemic changes and a 'just culture' over assigning blame.
• Innovative technologies like the VEINROM fluid delivery system show promise in preventing drug errors.
• A combination of vigilant healthcare professionals, a safe workplace culture, and organizational support is essential for effective medication error prevention.