Lecture on Medication Safety and Error Prevention

Introduction

• Incident Overview: A healthy child scheduled for elective ear surgery died due to a medication error involving epinephrine.
  • Incorrect concentration of epinephrine (1:1000) was injected instead of the intended anesthetic.
  • The situation led to a sense of dread and panic among healthcare providers.

Medication Errors

• Definition: Medication errors are preventable events leading to inappropriate medication use or harm.
• Sources:
  • Errors often occur during medication administration in hospital settings.
  • Particular concern for anesthesia professionals with sparse data but frequent errors.

Statistics and Data

• ASA Closed Claims Database:
  • Medication errors account for 4% of cases.
  • Types of errors: substitution errors, insertion errors, incorrect dosing.
  • Significant adverse effects occurred in nearly 50% of claims.

Causes of Medication Errors

• Lack of standardization and protocols.
• Production pressures and absence of checks and balances in operating rooms (OR).
• Common errors include syringe swaps, wrong drug selection, and labeling errors.
• Contributing factors: haste, inattention, communication failure, and fatigue.

Recommendations and Strategies

• Safe Practices:
  • Emphasize standardized labeling, proper syringe labeling, and color coding.
  • Address system changes rather than relying on flawless human performance.

STPC Paradigm

• Standardization: Focus on drug dosages, concentrations, and preparation methods.
• Technology: Use of barcoding, computer-assisted delivery, and error interception systems.
• Pharmacy: Encourage pre-mixed solutions and pre-filled syringes, with clinical pharmacists involved in the OR.
• Culture: Establish a non-punitive culture for error reporting and learning from adverse events.

Implementation in Practice

• Wake Forest University Baptist Medical Center Example:
  • Standardized drug infusions and syringes prepared by pharmacy.
  • Use of smart infusion pumps with standardized drug libraries.
  • Mandatory training for all staff on new practices.

Conclusion

• Adoption of the STPC Paradigm is encouraged to enhance medication safety.
• Anesthesia professionals and hospitals should collaborate for successful implementation.
• Improvement in medication delivery safety and clinician satisfaction is anticipated.

Additional Resources

• Educational materials and videos available on the APSF website.