Errors in the Operating Room

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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

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

Wrong sided procedures/blocks

Ha J. Preventing wrong-sided blocks. Int Anesthesiol Clin. 2024 Apr 1;62(2):53-57. doi: 10.1097/AIA.0000000000000436. Epub 2024 Feb 26. PMID: 38404146

O'Connor T, Papanikolaou V, Keogh I. Safe surgery, the human factors approach. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 2010;8(2):93-5. (In eng). DOI: 10.1016/j.surge.2009.10.004.

3. Al-Nasser B. Unintentional side error for continuous sciatic nerve block at the popliteal fossa. Acta anaesthesiologica Belgica 2011;62(4):213-5. (In eng).

4. Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ quality & safety 2014;23(4):299-318. (In eng). DOI: 10.1136/bmjqs-2012-001797.

5. Clarke JR, Johnston J, Finley ED. Getting surgery right. Annals of surgery 2007;246(3):395-403, discussion 403-5. (In eng). DOI: 10.1097/SLA.0b013e3181469987.

6. Stahel PF, Sabel AL, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Archives of surgery (Chicago, Ill : 1960) 2010;145(10):978-84. (In eng). DOI: 10.1001/archsurg.2010.185.

7. Handlogten K. Pediatric regional anesthesiology: a narrative review and update on outcome-based advances. International anesthesiology clinics 2024;62(1):69-78. (In eng). DOI: 10.1097/aia.0000000000000421.

8. Nixon HC, Wheeler P. Wrong-site lower extremity peripheral nerve block: process changes to improve patient safety. International anesthesiology clinics 2011;49(2):116-24. (In eng). DOI: 10.1097/AIA.0b013e3181ffc03f.

9. Deutsch ES, Yonash RA, Martin DE, Atkins JH, Arnold TV, Hunt CM. Wrong-site nerve blocks: A systematic literature review to guide principles for prevention. Journal of clinical anesthesia 2018;46:101-111. (In eng). DOI: 10.1016/j.jclinane.2017.12.008.

10. Angle JF, Nemcek AA, Jr., Cohen AM, et al. Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission "universal protocol for preventing wrong site, wrong procedure, wrong person surgery" to the practice of interventional radiology. Journal of vascular and interventional radiology : JVIR 2009;20(7 Suppl):S256-62. (In eng). DOI: 10.1016/j.jvir.2009.04.023.

11. Vacheron CH, Acker A, Autran M, et al. Insurance Claims for Wrong-Side, Wrong-Organ, Wrong-Procedure, or Wrong-Person Surgical Errors: A Retrospective Study for 10 Years. Journal of patient safety 2023;19(1):e13-e17. (In eng). DOI: 10.1097/pts.0000000000001080.