Detecting and eliminating medication errors

Detecting and eliminating medication errors

Monday 3 June, 1530-1630H, Room Strauss 1

The issue of medication safety is now appearing regularly in news stories in Europe and worldwide. This three-part session will address medication safety, focusing on the perioperative period.

In the first talk, Simon Peitersen (Patient Safety and Risk Management, Service Delivery and Safety, WHO,Geneva, Switzerland) will highlight that unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world.

“Globally, the cost associated with medication errors has been estimated at 42 billion US dollars annually,” explains Mr Peitersen. “Errors can occur at different stages of the medication use process. Medication errors occur when weak medication systems and/or human factors such as fatigue, poor environmental conditions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death.”

He will outline how multiple interventions to address the frequency and impact of medication errors have already been developed, yet their implementation is varied. A wide mobilisation of stakeholders supporting sustained actions is required. In response to this, WHO has identified Medication Without Harm as the theme for the third Global Patient Safety Challenge. “In this talk at Euroanaesthesia 2019, I will focus on the Third Global Patient Safety Challenge and how to detect and eliminate medication errors.”

After this, Dr Daniel Arnal-Velasco, ESA Patient Safety Quality Committee Chair and past president of the Spanish Safety Reporting System in Anaesthesia and Resuscitation(SENSAR), will explain that the challenge of delivering medication without harm in the perioperative period is unavoidable(1).

“As anaesthesiologists, we prescribe, prepare and administer up to 500.000 high risk medications throughout our professional life (2) with little space for verification and double checks,” says Dr Arnal, based at Hospital Universitario Fundacion Alcorcon, Spain.“We need to better understand all medication related events (MRE) to push harder and prioritise for specific strategies to reduce these.”

To reach the highest level of understanding, Dr Arnal says we must use all available information and Incident Reporting Systems (IRS), as learning tools, are one of these intelligence sources to find the most dangerous MRE patterns in the perioperative period. He says: “Despite their known limitations (3), anaesthesiologists have built and participated in several national IRS (4). One of the most active anaesthesia-related systems is SENSAR, a network of 104 anaesthesia and critical care departments in Spain, Chile and Uruguay (5).”

In his talk, Dr Arnal will present the results of a study of the first ten years of SENSAR to answer the questions about the relevance of MRE in relation with all reported incidents; when, along the medication process, do we suffer MRE? What are the most prevalent types of MRE? What medications are involved; and, most importantly, what is the relationship between these characteristics and the reported morbidity?”

In the final talk, Dr David Whitaker, retired from practice (formerly based at Manchester Royal Infirmary, UK) and who worked extensively on the Helsinki Declaration on Patient Safety, will give a presentation on a range of ways to remove medication errors, from labelling to prefilled syringes and beyond.

References for Dr Arnal’s talk:

  1. Arnal-Velasco D. Medication Errors in Anaesthesia: Let’s tackle the challenge. ESA Newsletter. 2019; 77. Available at https://newsletter.esahq.org/medication-errors-anaesthesia-lets-tackle-challenge/(accessed 12 May 2019)
  2. Orser BA, Chen RJB, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anesth Can d’anesthésie 2001; 48: 139–46
  3. Mitchell I, Schuster A, Smith K, Pronovost P, Wu A. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ Qual Saf 2016 [cited 2019 May 5]; 25: 92–9
  4. Reed S, Arnal D, Frank O, Gomez-Arnau JI, Hansen J, Lester O, Mikkelsen KL, Rhaiem T, Rosenberg PH, St Pierre M, Schleppers A, Staender S, Smith AF. National critical incident reporting systems relevant to anaesthesia: a European survey. Br J Anaesth. 2014 Mar;112(3):546-55.
  5. SENSAR. Sistema Español de Notificacion en Anestesia y Reanimacion. Participantes. Available at http://sensar.org/sobre-sensar/participantes/(accessed 12 May 2019)