Clinical Decision Support as a Prevention Tool for Medication Errors in the Operating Room: A Retrospective...

Area of Science:

• Anesthesiology
• Patient Safety
• Health Informatics

Background:

• Operating room medication errors pose significant patient harm risks.
• Electronic clinical decision support (CDS) is effective in other areas but underutilized in ORs.
• Limited adoption of CDS in operating rooms despite its potential.

Purpose of the Study:

• To quantify the percentage of intraoperative medication errors preventable by CDS algorithms.
• To assess the potential impact of CDS on operating room medication safety.

Main Methods:

• Retrospective analysis of 127 safety reports of medication errors from anesthesia clinicians (August 2020-August 2022).
• Errors were classified by stage, type, adverse event presence, severity, and CDS preventability.
• Chart review corroborated data; reviewer disagreements were resolved by consensus.

Main Results:

• 95% (76/80) of reported intraoperative medication errors were deemed preventable by CDS.
• Wrong medication (100%), wrong dose (100%), and documentation errors (100%) were highly preventable.
• Inadvertent bolus errors were least likely to be prevented by CDS (0%).

Conclusions:

• The majority of intraoperative medication errors are preventable with CDS.
• Future research should involve randomized controlled trials to validate CDS effectiveness in ORs.
• Implementing CDS can significantly enhance patient safety in the operating room.