Jane Smith was admitted for an elective laparoscopic cholecystectomy at an outpatient facility. She received midazolam in preoperative holding, and was brought to the operating room and received propofol and a general inhalational anesthetic. She also received a muscle relaxant and fentanyl. The case appeared to proceed without incident, but in the recovery room, the patient recounted that she felt pain, had difficulty breathing, and was able to recall specific conversations during the procedure. Upon review, it appeared that the syringes for the medications were mislabeled, leading to the medication error and intraoperative recall. A lawsuit was subsequently filed for PTSD and emotional distress.
Retrospective studies have established that medication errors do occur in the perioperative environment as much as in other areas of health care. A recent prospective study from Massachusetts General, however, revealed that the extent of those errors has been underestimated. This observational study published in Anesthesiology1 found that errors occur in 5 percent of all medication administrations in the operating room and in one-half of all procedures. One-third of these resulted in an adverse drug event with harm to the patient, and 80 percent were preventable.
Find out more key areas of risk and patient safety guidance related to perioperative medication errors by clicking below.