Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system
Yolanda Sanduende-Otero1, Javier Villalón-Coca2, Eva Romero-García3
1Department of Anaesthesiology, Hospital Pontevedra, Pontevedra, Spain.
Background:
Medication-related adverse events (MRE) in anaesthesia care are frequent and require a deeper understanding if we are to prevent medication harm.
Methods:
We searched for reported MRE from the Spanish Anaesthesia Incident Reporting System (SENSAR) database over a 10-yr period. SENSAR is a cross-national, multicentre system focused on perioperative and critical care. A descriptive analysis of independent variables, phase of medication process, type of MRE, and medication group involved, and their relationships with morbidity was conducted.
Results:
A total of 1970 MRE were identified from 7072 reported incidents. Patient harm was reported in 31% of the MRE. The administration phase was more frequent (42%) and showed the highest harm rate (44%) compared with other medication process phases. The most frequent types of MRE were wrong treatment regimen and wrong medication (55% of cases). The medication groups most commonly reported were those that alter haemostasis (18%), vasoconstrictor agents (13%), and opioids (10%). Vasoconstrictor agents, benzodiazepines, and neuromuscular blocking agents were the medication groups involved in patient harm four-fold more, and opioids three-fold more, than medications that alter haemostasis. The 1970 incidents were investigated and led to implementation of 4223 local corrective patient safety and quality improvement measures.
Conclusions:
Patient harm in the perioperative setting from medications remains a major issue for patients, hospital leaders, and clinicians. We found patterns and specific causes that can be mitigated through proven systems solutions, and should be taken into consideration in designing sustainable solutions for safe perioperative care.
Clinical Trial Registration:
NCT03615898.
Insights
Medication-related adverse events (MRE) in anesthesia are common, with administration errors causing significant patient harm. Identifying specific medication risks and implementing targeted safety solutions can improve perioperative care.
Area of Science:
- Anesthesiology
- Patient Safety
- Pharmacovigilance
Background:
- Medication-related adverse events (MRE) are frequent in anesthesia care.
- A deeper understanding of MRE is crucial for preventing medication harm.
Purpose of the Study:
- To analyze MRE reported in the Spanish Anaesthesia Incident Reporting System (SENSAR) database over a decade.
- To identify patterns, causes, and relationships between MRE, medication types, and patient harm in perioperative settings.
Main Methods:
- Descriptive analysis of 1970 MRE from 7072 reported incidents in SENSAR (10-year period).
- Examination of independent variables, medication process phases, MRE types, medication groups, and their association with patient morbidity.
- Investigation of incidents and implementation of corrective patient safety measures.
Main Results:
- 31% of MRE resulted in patient harm.
- Medication administration phase (42% of MRE) had the highest harm rate (44%).
- Wrong treatment regimen and wrong medication were the most frequent MRE types (55%).
- Medications altering hemostasis (18%), vasoconstrictor agents (13%), and opioids (10%) were most reported.
- Vasoconstrictors, benzodiazepines, and neuromuscular blockers were associated with significantly higher harm rates compared to hemostasis agents.
Conclusions:
- Patient harm from medications in the perioperative setting remains a significant concern.
- Identified patterns and causes of MRE can be mitigated through systems solutions.
- Findings should inform the design of sustainable solutions for safe perioperative care.
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