Skip to main content Accessibility help
×
Hostname: page-component-848d4c4894-wzw2p Total loading time: 0 Render date: 2024-05-01T17:22:39.940Z Has data issue: false hasContentIssue false

7 - Errors in the Context of the Perioperative Administration of Medications

Published online by Cambridge University Press:  09 April 2021

Alan Merry
Affiliation:
University of Auckland
Joyce Wahr
Affiliation:
University of Minnesota
Get access

Summary

Medication errors are not random events, nor are they necessarily evidence of a lack of carefulness on the part of the practitioner concerned. To a substantial degree, the particular type of medication error that is likely to occur in a particular set of circumstances is predictable. Furthermore, each of these types of error will continue to occur at their current rate if we continue with current approaches to the management of medications in the perioperative period. Errors will not be reduced by ongoing calls for greater carefulness on behalf of individual practitioners. Instead, the need is for fundamental changes in the ways in which medications are presented, selected and administered to patients. Greater investment in systems-based initiatives to improve medication management is essential if medication safety is to improve. However, it is also essential for clinicians to engage with such initiatives if they are to be effective. Achieving this requires sustained effort by departments and institutions, informed by the principles of implementation science.

Type
Chapter
Information
Publisher: Cambridge University Press
Print publication year: 2021

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Leape, LL. Error in medicine. JAMA. 1994;272(23):18517.Google Scholar
Merry, AF, Webster, CS, Mathew, DJ. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Anesth Analg. 2001;93(2):38590.CrossRefGoogle ScholarPubMed
Merry, AF, Webster, CS, Hannam, J, et al. Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. BMJ. 2011;343:d5543.Google Scholar
Merry, AF, Brookbanks, W. Merry and McCall Smith's Errors, Medicine and the Law. 2nd ed. Cambridge, UK: Cambridge University Press; 2017.Google Scholar
Blumenthal, D. Making medical errors into “medical treasures”. JAMA. 1994;272(23):18678.Google Scholar
Reason, J. Human Error. New York, NY: Cambridge University Press; 1990.CrossRefGoogle Scholar
Leslie, K, Culwick, MD, Reynolds, H, Hannam, JA, Merry, AF. Awareness during general anaesthesia in the first 4,000 incidents reported to webAIRS. Anaesth Intensive Care. 2017;45(4):4417.CrossRefGoogle Scholar
Rouse, W. Models of human problem solving: detection, diagnosis and compensation for system failures. In: Johannsen, G, Rijnsdorp, JE, eds. Proceedings of IFAC/IFIP/IFORS/IEA Conference on Analysis, Design and Evaluation of Man-Machine Systems, Baden-Baden, Federal Republic of Germany. Vol 15. Issue 6. Oxford, UK: IFAC/Elsevier; 1982:16784.Google Scholar
Kahneman, D. Thinking, Fast and Slow. London: Penguin Books; 2011.Google Scholar
Thaler, R, Sunstein, C. Nudge: Improving Decisions about Health, Wealth and Happiness. New Haven, CT: Yale University Press; 2008.Google Scholar
Stanovich, KE, West, RF. Discrepancies between normative and descriptive models of decision making and the understanding/acceptance principle. Cogn Psychol. 1999;38(3):34985.Google Scholar
Stanovich, KE, West, RF. Individual differences in reasoning: implications for the rationality debate? Behav Brain Sci. 2000;23(5):64565; discussion 665–726.Google Scholar
Reason, J. Managing the Risks of Organizational Accidents. London: Routledge; 1997.Google Scholar
Reason, J. Human error: models and management. Br Med J. 2000;320:76870.Google Scholar
Gladwell, M. Blink. The Power of Thinking Without Thinking. New York, NY: Little, Brown; 2005.Google Scholar
Stiegler, MP, Tung, A. Cognitive processes in anesthesiology decision making. Anesthesiology. 2014;120(1):20417.Google Scholar
Merry, AF. To do or not to do? How people make decisions. J Extra Corpor Technol. 2011;43(1):P3943.Google Scholar
Endsley, M. The role of situation awareness in naturalistic decision making. In: Zsambok, CE, Klein, G, eds. Expertise: Research and Applications. Naturalistic Decision Making, Mahwah, NJ: Lawrence Erlbaum Associates; 1997:26983.Google Scholar
Patel, A, Nouraei, SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70(3):3239.CrossRefGoogle ScholarPubMed
Frerk, C, Mitchell, VS, McNarry, AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):82748.Google Scholar
Cook, TM, Woodall, N, Frerk, C. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth. 2011;106(5):61731.Google Scholar
Henderson, JJ, Popat, MT, Latto, IP, Pearce, AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004;59(7):67594.Google Scholar
Apfelbaum, JL, Hagberg, CA, Caplan, RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):25170.Google ScholarPubMed
Perkins, GD, Ji, C, Deakin, CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med. 2018;1(8):71121.CrossRefGoogle Scholar
Merry, AF, Weller, JM, Robinson, BJ, et al. A simulation design for research evaluating safety innovations in anaesthesia. Anaesthesia. 2008;63(12):134957.Google Scholar
Bagian, JP, Gosbee, J, Lee, CZ, et al. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv. 2002;28(10):53145.Google Scholar
Caplan, RA, Posner, KL, Cheney, FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265(15):195760.CrossRefGoogle ScholarPubMed
Weiser, TG, Haynes, AB, Lashoher, A, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22(5):36570.Google Scholar
R v Yogasakaran [1990] 1 NZLR 399.Google Scholar
Anonymous. Forgotten baby syndrome explained by neuroscientist. DailyMail Online Videos; 2015 Accessed January 3, 2020. https://www.dailymail.co.uk/video/news/video-1107664/Forgotten-baby-syndrome-explained-neuroscientist.htmlGoogle Scholar
Veisi, F, Salimi, B, Mohseni, G, Golfam, P, Kolyaei, A. Accidental intrathecal injection of tranexamic acid in cesarean section: A fatal medication error. APSF Newsletter. 2010;25(1):9. Accessed January 3, 2020. https://www.apsf.org/article/apsf-hosts-medication-safety-conference/Google Scholar
Hatch, DM, Atito-Narh, E, Herschmiller, EJ, Olufolabi, AJ, Owen, MD. Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate. Int J Obstet Anesth. 2016;26:715.Google Scholar
Runciman, B, Merry, A, Walton, M. Safety and Ethics in Healthcare: A Guide to Getting It Right. Aldershot, UK: Ashgate Publishing; 2007.Google Scholar
Jelacic, S, Bowdle, A, Nair, BG, et al. A system for anesthesia drug administration using barcode technology: The Codonics Safe Label System and Smart Anesthesia Manager. Anesth Analg. 2015;121(2):41021.Google Scholar
Dixon-Woods, M, Leslie, M, Tarrant, C, Bion, J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:70.Google Scholar
Martis, WR, Hannam, JA, Lee, T, Merry, AF, Mitchell, SJ. Improved compliance with the World Health Organization Surgical Safety Checklist is associated with reduced surgical specimen labelling errors. N Z Med J. 2016;129(1441):637.Google Scholar
Haynes, AB, Weiser, TG, Berry, WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):4919.Google Scholar
Hannam, JA, Glass, L, Kwon, J, et al. A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. BMJ Qual Saf. 2013;22(11):9407.Google Scholar
Webster, CS, Larsson, L, Frampton, CM, et al. Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study. Anaesthesia. 2010;65(5):4909.CrossRefGoogle ScholarPubMed
Bowdle, TA, Jelacic, S, Nair, B, et al. Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. Br J Anaesth. 2018;121(6):133845Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×