One in 20 perioperative medication administrations included a medication error (ME) and/or adverse drug event (ADE). More than one third of the MEs led to observed ADEs, and the remaining two thirds had the potential for harm.

These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative MEs.

A total of 277 operations were observed with 3,671 medication administrations of which 193 (5.3%; 95% CI, 4.5 to 6.0) involved a ME and/or ADE. Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable.

The events included 153 (79.3%) errors and 91 (47.2%) ADEs.

In this prospective observational study, anesthesia-trained study staff (anesthesiologists/nurse anesthetists) observed randomly selected operations at a 1,046-bed tertiary care academic medical center to identify MEs and ADEs over 8 months.

Read More