Clinical Issue Presentation: Medication Error in Anesthesia

Medication errors in healthcare, especially in anesthesia, pertain to giving patients the wrong medication or dose, which might have unfavorable effects. Medication errors can happen anywhere, from prescription and preparation to administration. Using the case of Mr. H as a real-world example, this talk aims to investigate the clinical problem of drug errors in anesthesia. The talk will cover the history and importance of medication errors in healthcare settings, patient safety issues, related healthcare expenses, and a detailed case analysis to identify the underlying causes of the error. Together with outlining goals, objectives, and anticipated outcomes, the presentation will also use the body of existing literature to suggest evidence-based interventions and talk about using tools for quality improvement. In order to guarantee long-term improvements in medication safety, the presentation will also highlight the value of cooperation and teamwork in minimizing medication errors and provide a sustainability plan.

Background and Significance

Medication errors in healthcare settings refer to faults that occur during the prescription, preparation, delivery, and observation of pharmaceuticals. These mistakes can happen at several points throughout the medicine use process, resulting in unfavorable outcomes like patient injury, extended hospital stays, and higher medical expenses. Medication mistakes influence patients, healthcare practitioners, organizations, and healthcare systems (Aldossary et al., 2021). Medication errors can have serious repercussions; in fact, some studies include them as one of the world’s leading causes of mortality. While drug errors are not uncommon in many healthcare professions, they are especially risky in operating rooms (OTs) because of their high-stress and time-sensitive nature. As they prepare and deliver powerful anesthetic drugs, anesthesia clinicians are essential to the OT. The research shows that these medical professionals deal with pharmaceutical errors regularly, emphasizing how urgent it is to solve this problem (Aldossary et al., 2021). A multimodal approach is necessary to prevent pharmaceutical errors in anesthesia and healthcare settings. Enhancing communication between healthcare practitioners, implementing double-checking procedures, adopting better labeling standards, and minimizing error-causing variables, including hurry and heavy workloads, are examples of how to do this. Furthermore, it is critical to create a culture that supports error reporting without worrying about medicolegal fallout. Safer medical procedures and better patient outcomes can result from research and initiatives targeted at comprehending and reducing drug errors.

The expense of healthcare is a significant problem in the anesthesia profession, particularly when it comes to drug errors. Errors in medication administration can hurt patients, which has a domino effect on finances. These expenses cover various topics, such as prolonged hospital stays, legal responsibilities, and costs related to managing adverse events (Hakimoglu et al., 2015). The previously cited instance of Mr. H provides a stark example of the financial hardship that pharmaceutical errors in anesthesia can cause. In this instance, a critical adverse event was caused by the administration of an excessive amount of insulin during surgery. This miscalculation resulted in further expenses, such as more extended hospital stays, possible legal actions, and the requirement for extra medical interventions. That shows how prescription errors in anesthetic practice have real-world financial repercussions.

A diversified approach is necessary to address the costs of healthcare associated with drug errors in anesthesia. Error prevention is crucial and can be achieved by strictly double-checking medication dosages, better team communication, and increased education and awareness among anesthesiologists and other healthcare professionals (Hakimoglu et al., 2015). In addition to aiming for a safety culture, anesthesia providers need to be alert of the expenses linked to pharmaceutical errors. Ultimately, this will result in a more patient-safe and economically viable healthcare system by allowing healthcare facilities to limit the financial impact of unfavorable events, lower their legal responsibilities, and encourage practical resource usage. This emphasizes how important it is to have a planned, all-encompassing approach to deal with drug errors and related associated costs in anesthesia practice.

Problem Statement

A medication error happened during surgery in the case of Mr. H, specifically with the delivery of insulin. The mistake was caused by giving out 10 ccs (cubic centimeters) of insulin under the false impression that each cc held 10 units of the drug. Each cc held 100 units of insulin. As a consequence, Mr. H was given an excessive amount of insulin, endangering his already fragile health. The healthcare professionals involved experienced anxiety and distress when they realized the mistake after the drug had been given. This talk should answer the following clinical question: What are the main reasons behind medication errors in anesthesia, and how can medical professionals and institutions avoid them to improve patient care and reduce associated costs?

Gap analysis

An effective technique for analyzing the underlying causes of medication errors in anesthesia is the “5 Whys” method. We can learn more about the elements that led to the error by posing “why” inquiries frequently:

1. Why did the administration error occur? The anesthesia provider administered the wrong dose of insulin.
2. Why did the provider make this mistake? The provider miscalculated the insulin dose.
3. Why was the dose miscalculated? The provider was fatigued from a long shift.
4. Why was the provider working such long hours? The hospital has staffing shortages.
5. Why does the hospital have staffing shortages? Budget constraints and high patient volumes are overwhelming the healthcare system.

Root causes of medication errors

The root causes of drug errors in anesthesia are complex problems that must be addressed. First off, as the senior resident’s example shows, anesthesia physicians frequently work long shifts and rigorous schedules, which can cause severe exhaustion and impair cognitive function and decision-making. Errors with medication are far more likely when one is tired. Second, a significant factor in these errors is either a lack of knowledge about specific medications or their proper dosages, emphasizing the necessity of thorough instruction and continuous training to guarantee healthcare personnel’s competency (Rayan et al., 2019). Furthermore, in the intricate healthcare setting, good communication is essential, and mistakes might result from a breakdown in communication or a failure to double-check medicine quantities. Errors in medicine administration can also occur due to hospitals’ staffing shortages, which may force medical staff to work longer shifts and become more exhausted and burned out. Finally, the lack of uniform and clear pharmaceutical packaging and labeling might lead to misunderstandings and mistakes when administering the drug. It is essential to address these underlying issues to improve patient outcomes and augment medication safety in anesthesia practice.

Analysis of the Underlying Issues

Medication errors in anesthesia are complicated problems with underlying causes that must be fully addressed. Human factors are a significant concern for anesthesia providers, including weariness and cognitive overload. To address these issues, techniques, including workload management, shift limitations, and regular breaks, are required. It is imperative to guarantee the proficiency and training of healthcare personnel, underscoring the necessity of ongoing education and skill enhancement. Error risk can be decreased by using standardized checklists and procedures for medicine administration, which offer precise and organized instructions (Rayan et al., 2019). Improving labor management and addressing staffing shortages can reduce the strain on healthcare providers. Investing in drug safety measures is also essential; these include double-checking processes, proper labeling and packaging, and protections against high-risk medications. By implementing focused interventions and addressing these underlying concerns, healthcare facilities can improve patient safety, decrease medication errors related to anesthesia, and reduce associated costs.

Literature Synthesis

Several essential themes, including clinical decision support tools, are revealed by the literature synthesis about preventing drug errors in anesthesia. The clinical decision support systems (CDSS) subject of the literature synthesis highlights the critical role CDSS plays in healthcare. When it comes to situations where there are drug interactions, CDSS is a highly effective technique for improving patient safety through the reduction of prescription errors. By recommending cost-effective alternatives, they help to restrict costs, enhance clinical management, and encourage adherence to clinical recommendations (Sutton et al., 2020). Additionally, by utilizing deep learning and artificial intelligence, CDSS is transforming diagnoses and eventually increasing diagnosis accuracy. By encouraging shared decision-making and patient participation, these technologies are strengthening the patient-centered care paradigm. Healthcare companies can fully realize the promise of CDSS to improve patient safety and quality of treatment by resolving issues with alert fatigue, workflow disruptions, and data quality.

Proposed Intervention Based on Evidence

Based on evidence from the current literature, suggested interventions to lower medication mistakes in anesthesia entail the creation and application of clinical decision support systems specific to perioperative medication. Medication dosing advice, drug-drug interactions, allergy alerts, double-check reminders, barcode scanning integration, real-time drug availability monitoring, computerized medication reconciliation, documentation support, and instructional modules are just a few of the capabilities that these systems include. These treatments seek to address the underlying causes of pharmaceutical errors in anesthetic practice by offering real-time guidance and safety checks (Ahsani-Estahbanati et al., 2022). This evidence-based strategy is consistent with systematic review findings that demonstrate the usefulness of electronic systems in lowering drug mistakes. By using these technologies, anesthetic care quality may be improved overall, patient safety could be significantly increased, and healthcare expenses linked to adverse events caused by errors could be decreased.

Quality Improvement Tools and Framework: Plan-Do-Study-Act (PDSA) Model

Plan

A PDSA model can be used as a continuous quality improvement strategy in response to drug errors in anesthetic cases. Addressing the underlying reasons and enhancing patient safety during the administration of anesthesia, the goal is to reduce medication errors (Vordenberg et al., 2018). Implementing shift limits to prevent provider fatigue, improving anesthesia provider education and training, standardizing medication protocols and checklists, fostering better professional communication, addressing staffing shortages, and improving medication labeling and packaging are just a few of the essential strategies in the plan.

Do

The intended changes must be implemented in a controlled manner during the “Do” phase. Enforcement of shift limits, holding training sessions, implementing standardized protocols and checklists, improving communication protocols, resolving staffing concerns, and working with pharmacy services to enhance medication labeling and packaging are a few examples of these modifications (Vordenberg et al., 2018). As a pilot project, these adjustments will be implemented inside a particular division or unit to gauge their efficacy.

Study

Data will be gathered to assess the effects of the changes implemented during the “Study” phase. This information is gathered from anesthesia doctors, nurses, and other medical professionals participating in the pharmaceutical administration process, as well as from monitoring medication errors, adverse events, and near-miss episodes (Vordenberg et al., 2018). To ascertain whether the adjustments have decreased medication mistakes and enhanced patient safety, the gathered data will be examined.

Act

Based on the findings of the study phase, decisions are made during the “Act” phase. The modifications will be evaluated for extension to other areas of the anesthesia department if the results demonstrate a notable decrease in medication mistakes and enhanced patient safety in the pilot department. Adjustments will be made if there are unanticipated effects or the changes do not have the expected effect. These could include improving policies, offering more training, or addressing particular problems during implementation (Vordenberg et al., 2018). Medication safety guidelines for anesthesia delivery will continue to improve as long as the modifications are continuously monitored and evaluated.

Rationale for Framework Choice

The Plan-Do-Study-Act (PDSA) paradigm is a well-founded framework for quality improvement when resolving pharmaceutical errors in anesthesia. Dealing with complicated challenges like pharmaceutical errors requires an iterative and continuous improvement strategy, which the PDSA model provides. It recognizes that in order to address the underlying causes and enhance patient safety successfully, solutions need to be modified and improved over time. Additionally, the PDSA model offers an organized method for addressing problems (Taylor et al., 2014). It leads medical professionals through organizing, carrying out, analyzing, and responding to findings. In order to treat medication errors methodically and ensure that all required precautions are taken to avoid them in the future, an organized strategy is imperative. Using data to inform decisions is essential when it comes to drug errors. By emphasizing data gathering and analysis, the PDSA model enables healthcare practitioners to make evidence-based decisions (Taylor et al., 2014). Understanding the effects of interventions and ensuring adjustments result in increased patient safety depends heavily on this data-driven approach. Because of its adaptability, the PDSA model ensures that the quality improvement process is efficient and flexible by allowing adjustments based on the results of each cycle.

Goals, Objectives, and Expected Outcomes

Goal

The primary objective is to lower anesthesia drug errors to increase patient safety, raise the standard of care, and lower related expenses.

Objectives

Objective 1: To implement shift limits and workload management strategies within the anesthesia department to address provider fatigue and cognitive overload.

• Measurable: Number of healthcare providers adhering to shift limits.
• Achievable: Resources allocated for implementing shift limits.
• Realistic: Guidelines and policies are in place to support shift limits.
• Time-specific: Implement within the next 6 months.

Objective 2: To enhance the training and education of anesthesia providers, ensuring they have the necessary knowledge and competence to prevent medication errors.

• Measurable: Percentage of anesthesia providers completing additional training.
• Achievable: Training programs available and accessible.
• Realistic: Commitment to ongoing education within the institution.
• Time-specific: Increase education efforts within the next 12 months.

Objective 3: To establish and enforce standardized medication protocols and checklists for anesthesia administration.

• Measurable: Compliance rate with medication protocols and checklists.
• Achievable: Development and dissemination of standardized protocols.
• Realistic: Training and resources to support protocol adherence.
• Time-specific: Full implementation within the next 9 months.

Objective 4: To improve communication and teamwork among healthcare professionals in medication administration.

• Measurable: Improved communication scores in staff surveys.
• Achievable: Training and communication improvement programs.
• Realistic: Commitment to enhancing interprofessional collaboration.
• Time-specific: Begin communication improvement initiatives within the next 6 months.

Objective 5: To address staffing shortages and optimize workforce management to reduce the pressure on healthcare providers.

• Measurable: Reduction in overtime hours worked by healthcare providers.
• Achievable: Revised staffing and scheduling plans.
• Realistic: Commitment to addressing staffing issues.
• Time-specific: Optimize staffing within the next 12 months.

Objective 6:To enhance medication labeling and packaging to minimize confusion during medication administration.

• • Measurable: Reduction in reported incidents of medication label-related errors.
  • Achievable: Implementation of improved labeling and packaging standards.
  • Realistic: Commitment to investing in medication safety measures.
  • Time-specific: Complete labeling and packaging improvements within the next 8 months.

Expected Outcomes

Outcome 1: Reduction of medication errors in anesthesia by 20%.

• • Measurable: Track error rates through incident reports and adverse event monitoring.
  • Achievable: By implementing the objectives mentioned.
  • Realistic: Based on previous improvement initiatives.
  • Time-specific: Achieve this outcome within the next 12 months.

Outcome 2: Improvement in patient safety indicators, including a 15% decrease in adverse events related to medication errors.

1. • Measurable: Analyze adverse event data.
   • Achievable: By implementing the objectives and interventions.
   • Realistic: Aligned with the level of commitment to patient safety.
   • Time-specific: See these results within the next 12-18 months.

Outcome 3: Achieve 90% adherence to standardized medication protocols and checklists.

1. • Measurable: Monitor compliance rates.
   • Achievable: Through proper training and reinforcement.
   • Realistic: Attainable with staff commitment and support.
   • Time-specific: Maintain high compliance rates within the next 9-12 months.

Outcome 4: Improved communication and teamwork, with at least a 20% increase in communication scores in staff surveys.

• Measurable: Survey data analysis.
• Achievable: Through communication improvement programs.
• Realistic: Realizable with a focused effort.
• Time-specific: See improved scores in staff surveys within the next 6-9 months.

Outcome 5: Reduction in healthcare costs associated with medication errors by 15%.

1. • Measurable: Analyze the reduction in expenses related to adverse events, legal liabilities, and prolonged hospital stays.
   • Achievable: Through the successful implementation of safety measures.
   • Realistic: Attainable through the prevention of errors.
   • Time-specific: Observe cost reductions within the next 18-24 months.

Teamwork and Collaboration

A vital component of the multimodal strategy to prevent drug errors in anesthesia and critical care is teamwork and collaboration. The effectiveness of risk management solutions is greatly enhanced by the collaboration of different healthcare professionals working together in a coordinated manner. To guarantee precise and prompt medication delivery during surgical procedures, anesthesia providers—including anesthesiologists and nurse anesthetists—must keep lines of communication open with surgical teams. Since nurses are typically in charge of preparing and administering medications in critical care units, working together is just as important. As specialists in medications, pharmacists can verify pharmaceutical orders, actively participate in medication reconciliation procedures, and give the medical team crucial educational support. Interdisciplinary committees or teams that maximize drug management safety should be established to develop further teamwork (Risk Management Analysis Committee of the French Society for Anesthesia and Critical Care & French Society for Clinical Pharmacy, 2017). Clinical educators are critical in ensuring that professionals receive continuous training, are updated on best practices, and are more alert to drug errors. With their power and resources, hospital managers should encourage a safety-conscious culture and provide the funds and resources required to execute safety protocols successfully.

Patients and their supporters can offer insightful feedback and aid in creating safer systems when included in the discussion alongside healthcare experts. A culture of shared responsibility is fostered, and errors can be detected and reported early when patients and their families are involved in medication safety discussions (Risk Management Analysis Committee of the French Society for Anesthesia and Critical Care & French Society for Clinical Pharmacy, 2017). In addition to complying with international safety standards and guidelines, this multifaceted collaboration inside healthcare facilities guarantees that the approach to medication safety is all-encompassing and flexible and can lower the incidence of medication errors.

XII. Sustainability Plan

A drug Safety Committee will be established to guarantee the long-term viability of drug error reduction programs in anesthesia. This committee, comprised of representatives from quality improvement specialists, nursing, anesthesia, surgery, and pharmacy services, will play a key role in maintaining and improving our medication safety culture. In addition to the abovementioned responsibilities, the committee will actively promote an environment that values ongoing education and awareness (Mutair et al., 2021). The team will regularly hold workshops, training sessions, and simulation exercises to ensure everyone is current on the most recent medication safety procedures and practices. Our healthcare providers will continue to be diligent in their commitment to medication safety by placing a high priority on continuing education and information exchange.

Furthermore, the sustainability plan will incorporate technology solutions. The Medication Safety Committee will keep a careful eye on the introduction of barcode scanning systems, electronic health records (EHRs), and computerized physician order entry (CPOE) systems. Real-time checks and notifications to proactively prevent medication errors will be made possible by this technology integration, significantly lowering the likelihood of medication administration errors caused by human error (Mutair et al., 2021). The drug safety program will continuously adapt to the most stringent patient safety requirements using state-of-the-art technologies.

In addition, interprofessional teamwork will be prioritized to guarantee the pharmaceutical safety program’s long-term success. It is critical that doctors, nurses, pharmacists, anesthesiologists, and other healthcare workers work well together as a team. Medication safety is a shared responsibility and open communication culture that the Medication Safety Committee will help to develop (Mutair et al., 2021). The committee will act as a communications and collaboration facilitator among these healthcare providers. Preventing prescription errors as a group and upholding a steadfast commitment to patient safety will be made possible by this cooperative approach.

Summary

Medication errors in anesthesia pose a severe risk to patients and the healthcare system, resulting in substantial financial losses. The fact that an incorrect insulin dosage calculation brought on Mr. H’s medication error emphasizes how urgently this issue has to be resolved. The underlying reasons for medication errors in anesthesia include problems with medication labeling and packaging, staffing shortages, inadequate training, provider weariness, and communication failures. A Plan-Do-Study-Act (PDSA) strategy is put forth to solve these problems. They are implementing several initiatives, including staffing shortages, improved prescription labeling, shift limitations, increased training, standardized processes, and improved communication. Reducing prescription errors, improving patient safety, and cutting related expenses are the objectives. Ensuring the viability of these activities will be largely dependent on the Medication Safety Committee and the incorporation of technological solutions. Encouraging teamwork and collaboration among various healthcare specialties is crucial for preserving a safety-oriented culture. In order to enhance patient outcomes and cut costs, tackling drug errors in anesthesia necessitates a thorough, data-driven, and cooperative strategy.

References

Aldossary, D. N., Almandeel, H. K., Alzahrani, J. H., & Alrashidi, H. O. (2021). Assessment of Medication Errors Among Anesthesia Clinicians in Saudi Arabia: A Cross-Sectional Survey Study. Global journal on quality and safety in healthcare, 5(1), 1–9. https://doi.org/10.36401/JQSH-21-9

Hakimoglu, S., Hancı, V., Karcıoglu, M., Tuzcu, K., Davarcı, I., Kiraz, H. A., & Turhanoglu, S. (2015). Cost-Conscious of Anesthesia Physicians: An awareness survey. Pakistan journal of medical sciences, 31(5), 1089–1094. https://doi.org/10.12669/pjms.315.7520

Rayan, A. A., Hemdan, S. E., & Shetaia, A. M. (2019). Root Cause Analysis of Blunders in Anesthesia. Anesthesia, essays and researches, 13(2), 193–198. https://doi.org/10.4103/aer.AER_47_19

Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ digital medicine, 3, 17. https://doi.org/10.1038/s41746-020-0221-y

Vordenberg, S. E., Smith, M. A., Diez, H. L., Remington, T. L., & Bostwick, J. R. (2018). Using the Plan-Do-Study-Act (PDSA) Model for Continuous Quality Improvement of an Established Simulated Patient Program. Innovations in Pharmacy, 9(2), 1–6. https://doi.org/10.24926/iip.v9i2.989

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). A systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ quality & safety, 23(4), 290–298. https://doi.org/10.1136/bmjqs-2013-001862

Ahsani-Estahbanati, E., Sergeevich Gordeev, V., & Doshmangir, L. (2022). Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews. Frontiers in medicine, p. 9, 875426. https://doi.org/10.3389/fmed.2022.875426

Risk Management Analysis Committee of the French Society for Anesthesia and Critical Care (SFAR), & French Society for Clinical Pharmacy (SFPC) (2017). Preventing medication errors in anesthesia and critical care (abbreviated version). Anesthesia, critical care & pain medicine, 36(4), 253–258. https://doi.org/10.1016/j.accpm.2017.04.002)

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines (Basel, Switzerland), 8(9), 46. https://doi.org/10.3390/medicines8090046)