Hypothesis: To assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, to evaluate their root causes, and to formulate targeted solutions to prevent them.
Methods: Anesthesia-trained staff observed randomly-selected operations at a single-center to identify MEs and ADEs over 8 months.
Results: 44.8% of operations included 1 or more ME or ADE. The most common types of MEs were “labelling errors” and “wrong dose.” One in twenty medication administrations involved an ME or ADE.
Strengths: Rigorous methodology for identifying MEs and ADEs which didn’t rely on self-reported errors.
Weaknesses: The different types of MEs and ADEs were not clearly defined. Some examples of MEs and ADEs were trivial.
Key Point: Rates of intraoperative medication errors and adverse drug events may significantly higher than previously reported.