-Published perioperative medicine error rates vary between 1 in 20 and 1 in 274 anaesthetics given
-Why are only 10% of errors reported voluntarily? Should near-misses be reported?
-Blame culture is still felt to pervade; why?
-Should error investigations re-create the narrative of what happened rather than focussing on the facts?
-Should goal conflicts be considered as a contributory factor to errors?
-Should medicine handling begin at medical school?
-How can we develop error wisdom?
-Are guidelines the answer? Surely they cannot cover every circumstance? Are they an overlay that might inadvertently simplify a complex situation into a dichotomous decision between right and wrong?
-How can fatigue be objectively measured in healthcare?
-Anaesthetists have their own self-check mechanisms that serve as a second check. These rituals vary between anaesthetists. Many trainees have experienced consultants saying “I do it this way” Trainees are then having to learn and remember bespoke processes. Is this an issue?
-The aim of any incident analysis is to reconstruct the sequence of events of what happened in real-time & recreate the mindset of the individuals present.
-Decisions could have been made in an evolving situation where the outcome, the error, was unknown until it happened
-There is a need to define peri-operative medication error. This should acknowledge the difference between the way medicines are prepared in a dispensary/ward and that during the peri-operative period.
For an exploration into these questions, please read the following publication. This study provides an insight into why peri-operative medication errors might occur, and what might be done to reduce them. Whilst some of the causes of errors, and strategies to reduce them, were in keeping with the literature, some new themes emerged or were reframed. This work suggests a collaborative and system-centred approach to addressing peri- operative medication errors that involves the organisation and individuals.
#perioperative #medicationerrors #medicationsafety #humanfactors #errorhandling #anaesthesia
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