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Medication safety in the perioperative setting: A comparison of methods for detecting medication errors and adverse
Melanie M Stipp1,2,3, Hao Deng1,4,2, Kathy Kong1,2
1Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
Abstract:
The purpose of this study was to evaluate perioperative medication-related incidents (medication errors (MEs) and/or adverse medication events (AMEs)) identified by 2 different reporting methods (self-report and direct observation), and to compare the types and severity of incidents identified by each method. We compared perioperative medication-related incidents identified by direct observation in Nanji et al's 2016 study[1] to those identified by self-report via a facilitated incident reporting system at the same 1046-bed tertiary care academic medical center during the same 8-month period. Incidents, including MEs and AMEs were classified by type and severity. In 277 operations involving 3671 medication administrations, 193 MEs and/or AMEs were observed (5.3% incident rate). While none of the observed incidents were self-reported, 10 separate medication-related incidents were self-reported from different (unobserved) operations that occurred during the same time period, which involved a total of 21,576 operations and approximately 280,488 medication administrations (0.004% self-reported incident rate). The distribution of incidents (ME, AME, or both) did not differ by direct observation versus self-report methodology. The types of MEs identified by direct observation differed from those identified by self-report (P = .005). Specifically, the most frequent types of MEs identified by direct observation were labeling errors (N = 37; 24.2%), wrong dose errors (N = 35; 22.9%) and errors of omission (N = 27; 17.6%). The most frequent types of MEs identified by self-report were wrong dose (N = 5; 50%) and wrong medication (N = 4; 40%). The severity of incidents identified by direct observation and self-report differed, with self-reported incidents having a higher average severity (P < .001). The procedure types associated with medication-related incidents did not differ by direct observation versus self-report methodology. Direct observation captured many more perioperative medication-related incidents than self-report. The ME types identified and their severity differed between the 2 methods, with a higher average incident severity in the self-reported data.
Insights
Direct observation identified significantly more perioperative medication errors and adverse medication events than self-report. Self-reported incidents, though fewer, were more severe, highlighting differences in detection methods for patient safety.
Area of Science:
- Patient Safety
- Medication Management
- Healthcare Quality Improvement
Background:
- Perioperative medication errors and adverse events pose significant risks to patient safety.
- Current incident reporting systems may not capture the full spectrum of these events.
- Comparing different detection methods is crucial for improving reporting accuracy.
Purpose of the Study:
- To evaluate perioperative medication-related incidents using self-report and direct observation.
- To compare the types and severity of incidents identified by each method.
- To assess the effectiveness of different reporting mechanisms in a tertiary care setting.
Main Methods:
- A comparative study analyzing incidents from direct observation and a facilitated incident reporting system.
- Data collected from 277 operations (direct observation) and 21,576 operations (self-report) at an academic medical center.
- Classification of medication errors (MEs) and adverse medication events (AMEs) by type and severity.
Main Results:
- Direct observation identified a higher incident rate (5.3%) compared to self-report (0.004%).
- Observed MEs included labeling, wrong dose, and omission errors; self-reported MEs were primarily wrong dose and wrong medication.
- Self-reported incidents were of significantly higher average severity than those identified by direct observation.
Conclusions:
- Direct observation is more effective in capturing the majority of perioperative medication-related incidents.
- The types and severity of medication errors differ between direct observation and self-report.
- Enhancing incident reporting systems is necessary to capture a broader range of medication safety events.
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