Medication errors are apparently significantly underreported by anesthesia providers, at least at certain institutions. These recent findings may reflect a culture of underreporting or fear of punitive action, despite the fact that approximately 10% of these reported medication errors caused at least temporary patient harm.
“As we know from the Institute of Medicine report about 15 years ago, medication errors and adverse drug events are a huge public health problem,” said Mark S. Hausman, MD, assistant professor of anesthesiology at the University of Michigan Medical School, in Ann Arbor, and chief of anesthesiology at the VA Ann Arbor Healthcare System. “In fact, 44,000 to 98,000 patients die every year as a result of what we think are preventable errors, many of which may be medication errors.
“So this is a single-institution perspective on the epidemiology and consequences of perioperative medication errors.”
Using self-reported institutional quality assurance data and data from the Multicenter Perioperative Outcomes Group—a consortium of international medical centers aggregating electronic health record and quality improvement data for performance improvement and outcomes research—a multicenter team of researchers gathered data from July 2006 through November 2015 for potential instances of medication error.
Very Low Reported Incidence
The researchers manually reviewed each electronic health record, anesthetic record and error report to capture epidemiological, resource utilization and adverse outcome data. Type and severity of errors were characterized using National Coordinating Council for Medication Error Reporting and Prevention definitions. The current analysis represents single-center findings from the University of Michigan.
After performing these reviews, the researchers found 238 self-reported medication errors out of 434,554 total cases, for an incidence of 5.5 self-reported medication errors per 10,000 cases. “If you think about it, this is an incredibly small incidence of medication errors, since we’re looking over more than nine years of data,” Dr. Hausman said.
“We know that medication errors are underreported; this is yet another bit of evidence to show that they are grossly underreported, at least in our institution, and I suspect in many others.”
Antibiotics and opioids were the most common drug classes involved in medication errors (Table). Half of reported errors were IV boluses.
“When we looked at the types of errors, the most common were judgment errors, such as giving a patient a cephalosporin when they have a documented penicillin allergy,” Dr. Hausman reported at the 2016 annual meeting of the American Society of Anesthesiologists (abstract A3102).
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“Just below that with respect to frequency was the wrong drug. This is your classic syringe swap where you meant to give medication A and you accidentally gave medication B, which was in a different syringe.”
With respect to the severity of the errors, 9.7% were found to cause at least temporary harm. Adverse outcomes included mechanical ventilation in the PACU (3.8%), unplanned admission or escalation of care (2.9%), unplanned intubation (2.6%), and case being canceled or significantly delayed (1.7%).
“No mortalities were observed,” Dr. Hausman reported. “We also had one case of unplanned arterial line placement.”
These results, Dr. Hausman concluded, demonstrate that there is significant room for improvement when it comes to self-reporting of medication errors among health care providers. “The incidence that we captured is astonishingly low,” he noted. “By comparison, other studies have found medication errors more in the range of one in 100 to one in 400. So we’re not doing a great job of reporting, to say the least.”
Human Nature a Factor
The other consideration, the researchers added, is the cost of care associated with such errors, especially because 10% caused temporary patient harm. “We’re pulling billing data to do an analysis of charges for the medication error patients and matched controls,” Dr. Hausman said.
As Richard H. Blum, MD, MSE, noted, human nature may go a long way toward explaining these results. “Are people sure that their reports are not going up to their chief of service or hospital leadership?” asked the associate professor of anesthesia at Harvard Medical School, in Boston. “Because if there’s any potential for punitive action, you’re not going to get anyone reporting.”
“It’s a nonpunitive system,” Dr. Hausman replied. “That said, there are certain cases that need to be reviewed for QA [quality assurance] purposes so that constructive feedback may be provided. This is an important part of our quality assurance and performance improvement process.”
“Many other institutions have found that self-reporting has really been a problem, whether it’s on a national or local scale,” Dr. Blum continued. “Do you have any thoughts on how to do it better? Because if you’re not getting the data, you’re not really understanding why it happens and nothing is going to improve.”
“I think education and emphasis are important,” Dr. Hausman responded. “I think we need to emphasize the importance of this. Cooper and colleagues did a study in 2012 [Can J Anaesth 2012;59:562-570] and found an incidence of one every few hundred. And they got to that by really emphasizing the importance of reporting. So that extra layer of education and encouragement is the difference.”