The Epidemiology and Consequences of Perioperative Medication … · Medication Errors: Unique Features of this Study • Required participating centers to query and share sensitive

The Epidemiology and

Consequences of Perioperative

Medication Errors

Mark S. Hausman, Jr., M.D.

Chief of Staff, VA Ann Arbor Healthcare System

Assistant Dean for Veterans Affairs, University of Michigan Medical School

Assistant Professor of Anesthesiology, University of Michigan Medical School

Objectives1. To understand the epidemiology of

perioperative medication errors: When are they likely to occur, what is the taxonomy of these errors, and what classes of medications are commonly involved?

2. To review the clinical consequences of perioperative medication errors

3. To understand the healthcare costs associated with perioperative medication errors

4. To review and summarize literature relevant to this topic and objectives 1-3

Additional Objectives

1. Provide some context regarding the

significant issue of medical errors in

US healthcare

2. Describe the effort underway to create

a safer healthcare industry in the US:

the High Reliability Organization

concept in healthcare

To Err Is Human: Building a

Safer Healthcare System

• 1999 Institute of

Medicine Report

• 44,000-98,000

deaths per year

from medical errors

• Launched modern

field of patient

safety

To Err Is Human: Building a

Safer Healthcare System

• Medical errors defined as a failure to

complete a planned action or the use of a

wrong plan to achieve an aim

• Preventable medical errors were estimated

to exert a total cost of between $17-29B

dollars per year in US

• Report concluded faulty systems, processes

and conditions drive medical errors, rather

than reckless behaviors

US Underperforms comparable countries with

regard to medical, medication and lab errors

Medication Errors and

Anesthesiology• Perioperative medication errors 3 times more

likely to cause harm than non-perioperative medication errors1

• Reflects unique features of anesthesia practice: providers prescribe, prepare, dispense and record medication administrations often without secondary review

• Anesthetic classes of medications

• Competing priorities for anesthesia provider attention

• Self-reported frequencies of perioperative medication errors range from 1:133 to 1:450 cases2-5

1. Hicks, R.W., et al., 2006 MEDMARX data report: a chartbook of medication error findings from the perioperative settings from 1998-2005. USP Center for

the 2. Advancement of Patient SAfety 2006; Rockville, MD.

3. Cooper, L., et al., Influences observed on incidence and reporting of medication errors in anesthesia. Can J Anaesth, 2012. 59(6): p. 562-70.

4. Llewellyn, R.L., et al., Drug administration errors: a prospective survey from three South African teaching hospitals. Anaesth Intensive Care, 2009. 37(1): p.

93-8.

5. Webster, C.S., et al., The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care, 2001. 29(5): p. 494-500.

Stages of Medication

Administration

1. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology.

2016;124(1):25-34.

Medication Errors and

Anesthesiology

• 39-94% of anesthesia providers, when

surveyed, have acknowledged

committing a medication error in the

past1-5

• Is it possible we are not very good at

recognizing and self-reporting

medication errors?

1. Gordon, P.C., R.L. Llewellyn, and M.F. James, Drug administration errors by South African anaesthetists--a survey. S Afr Med J, 2006. 96(7): p. 630-2.

2. Labuschagne, M., et al., Errors in drug administration by anaesthetists in public hospitals in the Free State. S Afr Med J, 2011. 101(5): p. 324-7.

3. Orser, B.A., R.J. Chen, and D.A. Yee, Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anaesth, 2001. 48(2): p. 139-46.

4. Perel, A., et al., Anaesthesiologists' views on the need for point-of-care information system in the operating room: a survey of the European Society of

Anaesthesiologists. Eur J Anaesthesiol, 2004. 21(11): p. 898-901.

5. White, S.M., N. Deacy, and S. Sudan, Trainee anaesthetists' attitudes to error, safety and the law. Eur J Anaesthesiol, 2009. 26(6): p. 463-8.


2016;124(1):25-34.

• Prospective, observational study

• Anesthesia trained study staff observed

277 operations and 3,671 medication

administrations at a tertiary care hospital

over an 8 month period of time

• Outcomes of interest: incidence of

medication errors and adverse drug

events


2016;124(1):25-34.

• Found that 1:20 perioperative medication administrations resulted in either medication error or adverse drug event

• 1:2 anesthetic cases

• More than one third of errors resulted in patient harm, and the remaining 2/3 had the potential to cause harm

• One third of medication errors resulted in an adverse drug event

• 79% of medication errors either caused or had potential to cause patient harm

• Over two thirds of realized or potential patient harm categorized as serious


2016;124(1):25-34.

Definitions of Severity: Nanji

et al.

Types of Medication Errors:

Nanji et al.

Evaluation of Perioperative

Medication Errors: Nanji, Et al.

• Strengths:

• Prospective observational study

• Does not rely on self reporting- insight into true medication error rate

• Clinical consequences of observed medication errors

• Limitations:

• Single center

• Did not use standardized definitions (NCCMERP)

• No cost analysis

The Epidemiology and Consequences of

Perioperative Medication Errors: Study

Hypothesis and Aims

Perioperative medication errors occur not infrequently, and may result in meaningful incremental healthcare resource consumption and patient harm.

This study sought to:

1) Determine the epidemiology of perioperative medication errors by:

1) Leveraging an international Anesthesiology research collaborative: The Multicenter Perioperative Outcomes Group (MPOG)

2) Utilizing National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) taxonomy and standardized definitions

2) Determine the consequences of errors in terms of added healthcare resource consumption and patient harm

Project dissemination to date:

ASA Conference, 2016 – poster presentation

ASA Conference, 2017 – poster presentation

Anesthesiology News, April 2017

Medication Errors: Unique

Features of this Study

• Required participating centers to query and share sensitive QA data (10 sites)

• Mix of automated data extraction and chart review

• Customized data entry tool built to be used along side MPOG chart viewer

• Novel methodology for chart review was established (3 reviewers per case)

• Chart reviewer requisites and training had to be established.

• Requested participating centers to query and share cost data

• Industry sponsored study (Becton, Dickinson & Co.)

Highlighted Results

• 659 conformed self-reported medication error cases out of 1,889,736 = incidence of 3.5 per 10,000 cases

• 52% of reported medication errors required additional monitoring or caused at least temporary patient harm

• Adverse outcomes included unplanned intubation (6.7%), unplanned admission or escalation of level of care (4.1%), and mechanical ventilation in PACU (3.2%)

Type and Severity of Errors

Classes of Medications Associated

With Medication Errors

Type of Medication Error and

Associated Severity

Patient and

Case

Characteristics

for Medication

Error Cases

N=659

Case Characteristics • Among medication error cases, forty-five percent had

residents or providers-in-training present at the time of error,

compared to all cases in the MPOG database where residents

were present for 32% of cases.

• Fifty-eight percent of medication errors occurred in patients

with ASA status 3 or 4, whereas ASA 3 or 4 patients account

for only 43% of our eligible cases. These findings are

consistent with a previous report that provider experience and

patient comorbidities are contributing factors to perioperative

medication errors.1

• The finding that 23% of medication errors involved a

deficiency in monitoring is a significant epidemiologic insight

into this important issue.

1. Cooper L, DiGiovanni N, Schultz L, Taylor AM, Nossaman B. Influences observed on incidence and reporting of medication errors in anesthesia. Can J

Anaesth. 2012;59(6):562-570.

Cost Consequences of Perioperative

Medication Errors

Discussion• Our self-reported incidence of 3.5 medication

errors per 10,000 cases is lower than previously reported anesthesia medication error rates.

• The majority (52%) of self-reported medication errors caused at least temporary patient harm or required additional monitoring (severity D or higher).

• Antibiotics and opioids are the most common classes of medication associated with errors, and cardiovascular and paralytic (NMB) medication errors are associated with the highest severity of harm.

Discussion• Utilizing billing data from six of our participating medical

centers and institution specific charge-to-cost ratios (as published by CMS), we were able to determine that for the 52% of patients in this study with a class D severity error or higher, there was an associated 33% increase in cost of care ($3,823 per case)

• This finding is consistent with previously reported work which found a 35% increase in cost of care associated with preventable adverse drug events in an acute care setting.1

• >50% of medication error cases are associated with a >10% increase in cost of care, and 25% of error cases are associated with a >50% increase in cost of care.

• The revenue groups where the largest percentage difference was seen in medication error cases versus matched controls include drugs, blood products, intensive care days, CT scan, and inhalational therapy, which are all plausibly associated with medication errors and adverse drug events.

1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA.

1997;277(4):307-311.

Discussion• The prospective study looking at incidence of

perioperative medication errors found an error rate of 1:2 anesthetic cases, and an adverse drug event rate of 1:6 cases.1

• If we were to assume a 1:6 incidence proportion, and distribution of severity as observed in our study (52% cases D and higher), then a 20,000 per year surgical caseload hospital would incur over $12-13 million per year in perioperative medication error related costs.

• Additionally, 4,000 patients per year would be caused at least temporary harm in this hospital.


2016;124(1):25-34.

Key Points• Medical errors are of consequence

• Perioperative medication errors are particularly likely to cause harm

• We are not very good at reporting, characterizing and understanding perioperative errors

• Emerging insight into incidence, types, severities, contributing factors and consequences are important steps in meaningful process improvement work to come

The Joint Commission Zero

Harm Campaign

High Reliability Organization

An Organization that succeeds in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity

Five Principles of High Reliability

Organizations

The success of HRO’s in managing the unexpected is their effort to act

mindfully. This means that they are able to notice the unexpected in the

making if they cannot halt the event, they focus on containing it, if they

cannot contain it, they focus on restoration.

• Preoccupation with failure: HRO’s treat anomalies as symptoms of a problem with the system. Errors are reported promptly so problems can be found and fixed

• Sensitivity to operations: HRO’s are continuously sensitive to unexpected or changing conditions

• Reluctance to Simplify the situation: HRO’s take deliberate steps to comprehensively understand the work environment as well as the specific situation


Organizations

• Commitment to Resilience: Develop

the capability to detect, contain and

recover from errors.

• Deference to Expertise: Deferring to

the person with expertise to solve the

problem during upset conditions


Organizations

Adoption of Safety

& Improvement

Culture

HRO Principles: Illustrative

Example from Michigan Medicine

Maximizing Patient Safety in

Cataract Surgery

• Healthcare failure mode and effect

analysis conducted (HFEMA)

• 36 unique steps identified in continuum

of cataract care with potential for error

analyzed

• Team huddles with safety moments

• Culture of reporting: patient safety event

team created, expanded use of RCA

Questions and Discussion

Documents

The Epidemiology and Consequences of Perioperative Medication … · Medication Errors: Unique Features of this Study • Required participating centers to query and share sensitive