By Donnie Vinson, MD, Medical Director, CRH Anesthesia
There is no aspect of anesthesia that occupies a more important place in the safe management of our patients than the accurate administration of medications. Medication errors can be physically destructive to patients and emotionally destructive to clinicians. The first step to reduce errors is to heighten awareness. It is not difficult to inject drugs safely; rather, the challenge we face as anesthesia professionals is to administer perhaps half a million drugs during a professional lifetime – with 100% accuracy.
A medication error is defined as the inappropriate use of a drug that may result in harm. A significant medication error may be present as an actual negative outcome, or the potential for a negative outcome. An adverse drug event is defined as harm caused by the inappropriate use of a drug. When a medication is used properly with a subsequent adverse outcome, it is known as an adverse drug reaction.
Examples of common medication errors within the OR include incorrect dosage, incorrect medication, and wrong site administration. Drug errors represented 4% of claims in the ASA Closed Claims Project Report (2003). Drug errors are classified into the following categories (after Webster, et al):
- Omission: Drug not given
- Repetition: Extra dose of an intended drug
- Substitution: Incorrect drug instead of the desired drug (i.e., a swap)
- Insertion: A drug that was not intended to be given at a particular time or at any time
- Incorrect dose: Wrong dose of an intended drug
- Incorrect route: Wrong route of an intended drug
- Others: Usually a more complex event, not fitting the above categories
In summary, claims related to drug errors from the ASA Closed Claims Project database were classified according to mechanism. The most common distinct mechanisms were substitution, insertion, and incorrect dose; for example, 44% of these medication error claims involved incorrect dosing, 30% involved substituting one drug for an intended drug, 10% administration of a contraindicated drug, and 8% timing errors.
In our endoscopy suite environment, we have a more limited formulary compared to that found in the ORs in the hospital setting. We also find ourselves working in a more dimly lit location that serves to benefit the GI doctor’s view of the monitor. Studies confirm that the most frequent causes of drug errors were failure to check or misread vials or syringes, syringe swap, distraction, inattention, and pressure to proceed.
Like the hospital, we must also recognize that the operating room remains one of the last areas where “redundancy” or multiple checking — a hallmark of medication safety — is not a common practice. We choose, draw, and administer medication under our solitary watch.
Errors are multi-factorial in nature and are related to poorly designed medication labels and fonts, vial sizes, and unaddressed human factors, including confusing drug names. Errors often arise due to unintended interchange of drugs or confusion with look-alike vials.
Formal organization of the drug drawers and workspace should be used with attention to tidiness, placement of ampules and syringes, and separation of similar drugs. Anesthesia providers commonly use secondary cues (size of syringe, color of label or vial, location of syringe on the anesthesia tray) to choose the correct syringe, but these cues may decrease attention to reading the label. Drug mix-ups are among the most common reasons for anesthesia medication errors resulting in serious patient harm or death.
On a very personal note, my grandson was directly involved in a medication error less than three hours after birth last September. The 8 lb. 4 oz. product of an uncomplicated, full-term pregnancy and uneventful delivery was to receive his Hepatitis B vaccine and initial dose of Vitamin K; instead, he received Methergine — and yes, that is no typo.
Importantly, the error was reported by the administering RN, who immediately intervened. Within the hour, he developed extreme vasoconstriction: oxygen saturations fell into the 80s, necessitating ventilatory support, intubation, and emergent transport to a Level III NICU. The most critical time was calculated to be equivalent to five half-lives of the drug. Therapy focused on maintaining end-organ perfusion and ventilatory support.
After a six-day stay, he was released home. The unnamed facility immediately implemented three policy changes related to this event, despite already having labeling and EMR scanning in place. Today, my grandson continues to meet developmental milestones and bring joy to our family.
It is true that failure to properly identify the medication is a final common pathway for nearly all medication errors, but it is equally true that simply recommending this action fails as a high-reliability safety measure. I want to emphasize the integrity of the clinician who makes the error — because “sweeping it under the rug” can lead to even more devastating outcomes.
As always, be vigilant.
