Related Experiment Video
Updated: Jan 8, 2026
Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia
Published on: May 26, 2023
Primary anesthesia provider characteristics and risk factors for intraoperative medication errors: a retrospective
Kohei Ikeda1, Masayoshi Koike2, Seirin Yamazaki2
1Department of Anesthesiology, The Jikei University School of Medicine, 3- 19-18, Nishi-Shimbashi Minato-ku, Tokyo, Japan. kikeda.jk@gmail.com.
Background:
Intraoperative medication errors, although uncommon, can result in considerable patient harm. Evidence remains limited regarding anesthesia provider-level and perioperative risk factors. This study aimed to evaluate whether anesthesia provider characteristics-particularly experience level and team composition-are statistically associated with intraoperative medication errors after multivariable adjustment.
Methods:
We conducted a retrospective observational study of 100,093 surgical cases managed under anesthesia at a university-affiliated tertiary hospital in Japan between August 2011 and December 2023. Data were extracted from an electronic anesthesia record system linked to institutional medical records. Medication errors were mainly identified through anesthesia provider self-reporting, supplemented by reports from operating room nurses. Predictor variables included patient characteristics, procedural details, and the main explanatory variable was anesthesia provider configuration: attending, and resident or intern under the supervision of an attending anesthesiologist. Firth's penalized logistic regression was used to adjust for confounding variables identified via a directed acyclic graph.
Results:
Intraoperative medication errors occurred in 102 of 100,093 procedures (0.10%). Compared with attending anesthesiologists, the odds of medication error-adjusted for the familywise error rate (FWER) using the Holm-Bonferroni method-were significantly higher when care involved residents [OR 2.713; 95% CI, 1.283-6.815; P = 0.007] or interns [OR 3.272; 95% CI, 1.508-8.368; P = 0.003]. After multiplicity adjustment, no other factors-including age, American Society of Anesthesiologists Physical Status (ASA-PS) classification, and surgical urgency-were statistically associated with error risk. Sensitivity analyses confirmed the robustness of the main findings across different covariate sets.
Conclusions:
Anesthesia provider characteristics were statistically associated with intraoperative medication error risk. These findings suggest the need for strengthened supervision, structured team roles, and systems-based safeguards in perioperative medication safety.
Insights
Anesthesia provider experience significantly impacts intraoperative medication errors. Less experienced residents and interns showed higher error rates, highlighting the need for enhanced supervision and safety systems in anesthesia care.
Area of Science:
- Anesthesiology
- Patient Safety
- Health Informatics
Background:
- Intraoperative medication errors, though infrequent, pose significant patient harm risks.
- Limited evidence exists on anesthesia provider-level and perioperative risk factors for these errors.
- This study investigates the association between anesthesia provider characteristics and medication errors.
Purpose of the Study:
- To evaluate if anesthesia provider experience and team composition correlate with intraoperative medication errors.
- To identify specific anesthesia provider roles associated with increased medication error risk.
- To inform strategies for improving perioperative medication safety.
Main Methods:
- Retrospective observational study of 100,093 anesthesia cases (August 2011-December 2023).
- Data extracted from electronic anesthesia records and linked institutional medical records.
- Firth's penalized logistic regression used to analyze anesthesia provider configuration (attending, resident, intern) and other factors.
Main Results:
- A low rate of intraoperative medication errors (0.10%) was observed.
- Residents (OR 2.713) and interns (OR 3.272) had significantly higher odds of medication errors compared to attending anesthesiologists, after adjustment.
- No other factors, including patient ASA-PS or surgical urgency, were statistically linked to error risk.
Conclusions:
- Anesthesia provider characteristics, particularly experience level, are statistically linked to intraoperative medication error risk.
- Findings underscore the necessity for enhanced supervision and structured team roles in anesthesia.
- Systems-based safeguards are crucial for improving perioperative medication safety.
Related Concept Videos
01:24Parenteral Anesthetics: Overview
01:24General Anesthesia: Overview
General anesthesia induces unconsciousness in the whole body, while the others target specific areas or sensations. It is administered to minimize adverse effects, maintain...
01:29Local Anesthetics: Clinical Application as Epidural Anesthesia
Since epidural anesthetics can be infused through an epidural catheter, all types of drugs, including short-acting ones, can be administered. Chloroprocaine and lidocaine are examples of short and long-duration anesthetics, respectively. Bupivacaine...
01:22Stages of General Anesthesia
01:20Inhalational Anesthetics: Overview
01:13Local Anesthetics: Pharmacokinetics