Errors in the Operating Room: Difference between revisions

Latest revision as of 17:05, 12 December 2024

This is a Stub Notice. This page has not been completed. You can work on this page by signing in and going to the Edit tab. Thanks for helping to make PedsAnesthesia.Net Wiki useful.

Go to the Main Page to see the Topic Outline.

Go to the Generalized Suggested Outline for information on case-specific details for each page.

Go to the Test Page for examples on how to use references in the page.

Relevant Article Depot:

Tweetorial: Learning from Errors in the OR

Preventing Medication Errors in Pediatric Anesthesia: A Systematic Scoping Review

Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia

The German guidelines for medication safety in pediatric emergencies

Medication safety in pediatric anesthesia: An educational review and a call to action

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Evaluation of Perioperative Medication Errors and Adverse Drug Events

APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice

Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative

Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm

Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study

Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability

Institute of Medicine (US) Committee on Quality of Health Care in America: To Err is Human: Building a Safer Health System

Highly S. An Encounter with an Error Trap

Cognitive errors detected in anaesthesiology: a literature review and pilot study

Educational Review: Error traps in anesthesia for pediatric liver transplantation

Clinical impact of task interruptions on the anaesthetic team and patient safety in the operating theatre

Handling injectable medications in anaesthesia - Guidelines from the Association of Anaesthetists

Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-patient blood transfusion error: leveraging Technology to overcome human error in intraoperative blood component administration. Jt Comm J Qual Patient Saf. 2019 Mar; 45(3): 190-198. PMID: 30389466

The Joint Commission. Sentinel Events (SE). Comprehensive Accreditation Manual for Hospitals. Updated July 2021.

Posner KL, Kent CD, Mincer SL, Domino KB. Anesthetic risk, quality improvement, and liability. In: Barash PG, Cullen BF, Stoelting RK, et al., eds. Clinical Anesthesia. 8th ed. Philadelphia, PA: Wolters Kluwer; 2017: 101.

The impact of using prefilled syringes on a standard operating procedure for preparing injectable medicines in clinical areas

WFSA Tutorial: Distractions in the OR

WFSA: Introduction to the Morbidity & Mortality Tool Kit for LMICs

A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study

The vial can help: Standardizing vial design to reduce the risk of medication errors

Institute for Safe Medication Practices

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. (In eng). DOI: 10.1097/aln.0000000000000904.

Kahneman D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol 2003;58(9):697-720. (In eng). DOI: 10.1037/0003-066x.58.9.697.

Jelacic S, Bowdle A, Nair BG, Kusulos D, Bower L, Togashi K. A System for Anesthesia Drug Administration Using Barcode Technology: The Codonics Safe Label System and Smart Anesthesia Manager. Anesthesia and analgesia 2015;121(2):410-21. (In eng). DOI: 10.1213/ane.0000000000000256.

Thomas JJ, Bashqoy F, Brinton JT, Guffey P, Yaster M. Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability. Hospital pharmacy 2022;57(1):11-16. (In eng). DOI: 10.1177/0018578720970464

Application of SEIPS and AcciMap to a patient safety incident

Bitan Y, O’Connor MF, Nunnally ME. The vial can help: Standardizing vial design to reduce the risk of medication errors. Int Anesthesiol Clin. 2024 Apr 1;62(2):58-61. Doi: 10.1097/AIA.0000000000000431. Epub 2024 Jan 22. PMID: 38251720.

Martin LD, Grigg ED, Verma S, Latham G, Rampersad SE, Martin LD: Decreased Medication Errors in Pediatric Anesthesia Practice: Outcomes from a Failure Mode and Effects Analysis. Pediatr Anesth 2017; 27: 571-80. (PMID: 28370645)

Grigg E, Martin LD, Ross FJ, Roesler A, Rampersad SE, Haberkern CM, Low DKW, Carlin K, Martin LD: Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study. Anesth Analg 2017; 124:1617-25. (PMID: 280079581)

YouTube: Dennis Quaid talks about his twins and medical negligence

Intracranial Nasogastric Tube Placement in a Nontrauma Patient

Relationship between mental effort and workload during routine anaesthesia

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16381

Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Disclosure of "nonharmful" medical errors and other events: duty to disclose. Arch Surg. 2012 Mar; 147(3): 282-6. PMID: 22430914

Garrouste-Orgeas M, Philippart F, Bruel C, Max A, Lau N, Misset B. Overview of medical errors and adverse events. Ann Intensive Care. 2012 Feb; 2(1): 2. PMID: 22339769

Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011 Jul; 21(7): 730-6. PMID: 21251144

@@ Line 2: / Line 2: @@
 [https://twitter.com/cap_mcawesome/status/1367828188114587650?s=21 Tweetorial: Learning from Errors in the OR]
+[https://pubmed.ncbi.nlm.nih.gov/35649513/ Preventing Medication Errors in Pediatric Anesthesia: A Systematic Scoping Review]
+[https://onlinelibrary.wiley.com/doi/10.1111/pan.14535 Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia]
+[https://onlinelibrary.wiley.com/doi/10.1111/pan.14524 The German guidelines for medication safety in pediatric emergencies]
+[https://pubmed.ncbi.nlm.nih.gov/36239463/ Medication safety in pediatric anesthesia: An educational review and a call to action]
+[https://pubmed.ncbi.nlm.nih.gov/36239463/ Medication safety in pediatric anesthesia: An educational review and a call to action]
+[https://pubmed.ncbi.nlm.nih.gov/28370645/ Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia]
+[https://pubmed.ncbi.nlm.nih.gov/26501385/ Evaluation of Perioperative Medication Errors and Adverse Drug Events]
+[https://www.apsf.org/wp-content/uploads/newsletters/2010/spring/pdf/APSF201006.pdf APSF hosts medication safety conference: consensus group defines challenges and opportunities for improved practice]
+[https://pubmed.ncbi.nlm.nih.gov/28742772/ Medication Errors in Pediatric Anesthesia: A Report From the Wake Up Safe Quality Improvement Initiative]
+[https://journals.lww.com/pqs/Fulltext/2022/09000/Independent_Double_check_of_Infusion_Pump.6.aspx Independent Double-check of Infusion Pump Programming: An Anesthesia Improvement Effort to Reduce harm]
+[https://pubmed.ncbi.nlm.nih.gov/28079581/ Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study]
+[https://pubmed.ncbi.nlm.nih.gov/35521011/ Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability]
+[https://pubmed.ncbi.nlm.nih.gov/25077248/ Institute of Medicine (US) Committee on Quality of Health Care in America: To Err is Human: Building a Safer Health System]
+[https://www.hastam.co.uk/an-encounter-with-an-error-trap/ Highly S. An Encounter with an Error Trap]
+[https://pubmed.ncbi.nlm.nih.gov/22157846/ Cognitive errors detected in anaesthesiology: a literature review and pilot study]
+[https://pubmed.ncbi.nlm.nih.gov/36178188/ Educational Review: Error traps in anesthesia for pediatric liver transplantation]
+[https://www.bjanaesthesia.org/article/S0007-0912(23)00251-9/fulltext Clinical impact of task interruptions on the anaesthetic team and patient safety in the operating theatre]
+[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16095 Handling injectable medications in anaesthesia - Guidelines from the Association of Anaesthetists]
+Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-patient blood transfusion error: leveraging Technology to overcome human error in intraoperative blood component administration. Jt Comm J Qual Patient Saf. 2019 Mar; 45(3): 190-198. PMID: 30389466
+The Joint Commission. Sentinel Events (SE). Comprehensive Accreditation Manual for Hospitals. Updated July 2021.
+Posner KL, Kent CD, Mincer SL, Domino KB. Anesthetic risk, quality improvement, and liability. In: Barash PG, Cullen BF, Stoelting RK, et al., eds. Clinical Anesthesia. 8th ed. Philadelphia, PA: Wolters Kluwer; 2017: 101.
+[https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16166 The impact of using prefilled syringes on a standard operating procedure for preparing injectable medicines in clinical areas]
+[https://resources.wfsahq.org/atotw/distractions-in-the-or/ WFSA Tutorial: Distractions in the OR]
+[https://wfsahq.org/news/latest-news/introduction-to-the-morbidity-mortality-tool-kit-for-lmics/ WFSA: Introduction to the Morbidity & Mortality Tool Kit for LMICs]
+[https://pubs.asahq.org/anesthesiology/article/140/3/387/139424/A-Quality-Improvement-Initiative-to-Reduce-Adverse A Quality Improvement Initiative to Reduce Adverse Effects of Transitions of Anesthesia Care on Postoperative Outcomes: A Retrospective Cohort Study]
+[https://pubmed.ncbi.nlm.nih.gov/38251720/ The vial can help: Standardizing vial design to reduce the risk of medication errors]
+[https://www.ismp.org/ Institute for Safe Medication Practices]
+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. (In eng). DOI: 10.1097/aln.0000000000000904.
+Kahneman D. A perspective on judgment and choice: mapping bounded rationality. Am Psychol 2003;58(9):697-720. (In eng). DOI: 10.1037/0003-066x.58.9.697.
+Jelacic S, Bowdle A, Nair BG, Kusulos D, Bower L, Togashi K. A System for Anesthesia Drug Administration Using Barcode Technology: The Codonics Safe Label System and Smart Anesthesia Manager. Anesthesia and analgesia 2015;121(2):410-21. (In eng). DOI: 10.1213/ane.0000000000000256.
+Thomas JJ, Bashqoy F, Brinton JT, Guffey P, Yaster M. Integration of the Codonics Safe Label System(®) and the Omnicell XT(®) Anesthesia Workstation into Pediatric Anesthesia Practice: Utilizing Technology to Increase Medication Labeling Compliance and Decrease Medication Discrepancies While Maintaining User Acceptability. Hospital pharmacy 2022;57(1):11-16. (In eng). DOI: 10.1177/0018578720970464
+[https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/investigations-and-complaints/methodology-and-guidance-how-to-do-an-investigation/patient-safety-incident-response-framework-psirf/application-of-seips-and-accimap-to-a-patient-safety-incident-r11143/ Application of SEIPS and AcciMap to a patient safety incident]
+Bitan Y, O’Connor MF, Nunnally ME. The vial can help: Standardizing vial design to reduce the risk of medication errors. Int Anesthesiol Clin. 2024 Apr 1;62(2):58-61. Doi: 10.1097/AIA.0000000000000431. Epub 2024 Jan 22. PMID: 38251720.
+Martin LD, Grigg ED, Verma S, Latham G, Rampersad SE, Martin LD:  Decreased Medication Errors in Pediatric Anesthesia Practice:  Outcomes from a Failure Mode and Effects Analysis.  Pediatr Anesth 2017; 27: 571-80. (PMID: 28370645)
+Grigg E, Martin LD, Ross FJ, Roesler A, Rampersad SE, Haberkern CM, Low DKW, Carlin K, Martin LD:  Assessing the Impact of the Anesthesia Medication Template on Medication Errors During Anesthesia: A Prospective Study.  Anesth Analg 2017; 124:1617-25. (PMID: 280079581)
+[https://youtu.be/GEDMYsm3Nxs?si=iMH04qNn2g7a3vsj YouTube: Dennis Quaid talks about his twins and medical negligence]
+[https://pubs.asahq.org/anesthesiology/article/139/4/492/138452/Intracranial-Nasogastric-Tube-Placement-in-a Intracranial Nasogastric Tube Placement in a Nontrauma Patient]
+[https://www.bjanaesthesia.org/article/S0007-0912(24)00266-6/fulltext Relationship between mental effort and workload during routine anaesthesia]
+https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10.1111/anae.16381
+Chamberlain CJ, Koniaris LG, Wu AW, Pawlik TM. Disclosure of "nonharmful" medical errors and other events: duty to disclose. Arch Surg. 2012 Mar; 147(3): 282-6. PMID: 22430914
+Garrouste-Orgeas M, Philippart F, Bruel C, Max A, Lau N, Misset B. Overview of medical errors and adverse events. Ann Intensive Care. 2012 Feb; 2(1): 2. PMID: 22339769
+Brandom BW, Callahan P, Micalizzi DA. What happens when things go wrong? Paediatr Anaesth. 2011 Jul; 21(7): 730-6. PMID: 21251144