Preventable adverse events can lead to serious patient harm and financial burden for individuals and organizations. Building off prior research estimating the incidence of perioperative medication errors, these researchers performed a systematic review to identify and quantify the downstream costs and patient harm due to medication errors. The researchers estimated that the total additional annual cost of care due to perioperative medication errors was $5.33 billion dollars.

Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.

Concern for improved prescribing of opiates motivated the development of programs and policies that have inadvertently caused new problems. This commentary discusses the impact of nonopioid use during surgery as a patient preference. It discusses the potential for adverse impacts of the strategy while recognizing the unique situation of perioperative use of pain medications.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.

The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities seeking to reduce medical error. The authors highlight the collaboration strategies that the specialty embraced as a key component of its success.

Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks.  This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.

Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes. Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare adrenal tumor led to a reduction in drug delivery and system errors, as well as increased drug adherence.

Harm from opioids is a widely recognized patient safety issue, and potential harm associated with short-term use is a growing area of concern. This analysis of a previously opioid-free surgical population identified a high rate of potential opioid-related adverse drug events (ORADEs); risk was strongly associated with route and duration of post-operative opioid administration. The presence of an ORADE was associated with longer postoperative length of stay, higher hospitalization costs, lower odds of discharge home, and higher odds of death.

The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.  

Incident reporting systems are central to most patient safety programs, but studies have identified barriers to effective use. This study used clinical vignettes describing a medication error or near miss to explore error awareness and attitudes towards reporting and disclosure among anesthesiologists. Approximately one-third of anesthesiologists recalled having had medication safety training. Perioperative medication error awareness and assessment of potential harm were variable, and the likelihood of patient disclosure and incident reporting was low. Education programs utilizing vignettes should be utilized to raise awareness about error reporting and disclosure behaviors.  

This commentary explores how gaps in legal and regulatory structure affect anesthesia medication safety. The author advocates for use of a public health law framework to prevent certain types of perioperative medication errors made by anesthesiologists. Policy approaches that require organizations to provide prefilled syringes and barcoding scanners are suggested to avoid vial- and syringe-related mistakes.

Underreporting of adverse events is a known shortcoming of incident reporting systems. This pre–post study demonstrated an increase in reporting of perioperative adverse events through a multifaceted intervention that included interviewing clinicians about barriers to reporting and creating a local requirement to complete adverse event reports using an electronic incident reporting system. The study team concluded that mandated reporting addresses underuse of incident reporting systems.