Describing and Quantifying Wrong-Patient Medication Errors Through a Study of Incident Reports.

Purpose: Our aim was to inform a new definition of wrong-patient errors, obtained through an analysis of incident reports related to medication errors. Methods: We investigated wrong-patient medication errors in incident reports voluntarily reported by medical staff using a web-based incident reporting system from 2015 to 2016 at a university hospital in Japan. Incident report content was separately evaluated by four evaluators using investigational methods for clinical incidents from the Clinical Risk Unit and the Association of Litigation and Risk Management. They investigated whether it was the patient or drug that was incorrectly chosen during wrong-patient errors in drug administration in incident reports and assessed contributory factors which affected the error occurrence. The evaluators integrated the results and interpreted them together. Results: Out of a total 4337 IRs, only 30 cases (2%) contained wrong-patient errors in medication administration. The cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients through the investigation of wrong targets. After a discussion, the evaluators concluded that the patient - drug/CPOE screen mismatch, caused by choosing the wrong patient, drug, or CPOE screen (mix-ups), occurred in the wrong-patient medication errors. These errors were caused by three conditions: (1) where two patients/drugs were listed next to one another, (2) where two patients' last names/drugs' names were the same, and (3) where the patient/drug/CPOE screen in front of the staff involved was believed to be the correct one. Additionally, these errors also involved insufficient confirmation, which led to failure to detect and correct the mismatch occurrences. Conclusion: Based on our study, we propose a new definition of wrong-patient medication errors: they consisted of choosing a wrong target and insufficient confirmation. We will investigate other types of wrong-patient errors to apply this definition.

[Postoperative pain management using subcutaneous fentanyl and ketamine after abdominal gynecologic surgery].

BACKGROUND: Subcutaneous opioid is one way of managing postoperative pain in patients undergoing anticoagulant therapy. We have evaluated the safety and the efficacy of postoperative pain management using subcutaneous fentanyl and ketamine after abdominal gynecologic surgery. METHODS: Written informed consent was obtained from 50 ASA physical status 1 or 2 female patients aged between 20 and 65. Patients were randomized to one of 5 groups. Group 1, 2 and 3 received 25, 35 and 50 microg x h(-1) subcutaneous fentanyl infusion, respectively. Group 4 received 25 microg x h(-1) fentanyl and 2 mg x h(-1) ketamine subcutaneously; group 5 received 25 microg x h(-1) fentanyl and 4 mg x h(-1) ketamine subcutaneously. General anesthesia was administered to all patients. Two hours after induction, subcutaneous infusion of fentanyl and ketamine was started in the patients and discontinued 24 hours after the operation. All patients were assessed twice, at 4 hours and at 24 hours after operation. Blood gas analysis was performed. Number of analgesic administration required during the 24 hours after operation was recorded. Groups 1, 2, 3 and groups 1, 4, 5 were evaluated as one group, respectively. Group differences were analyzed by variance analysis. Differences of analgesic administration were analyzed with Kruskal-Wallis test. RESULTS: As to anesthetic requirement during the 24 hours after operation, there were no significant differences among treatment groups. With respect to blood gas analysis, only individuals receiving subcutaneous 25 microg x h(-1) fentanyl and 4 mg x h(-1) ketamine maintained high PaO2 4 hours after the operation (P<0.05). CONCLUSIONS: We recommend administration of 25 microg x h(-1) fentanyl and 4 mg x h(-1) ketamine subcutaneously, which maintains high Pao2 and requires less analgesic.

[Comparison of 8 mg and 10 mg hyperbaric bupivacaine during spinal anesthesia for cesarean section in Japanese parturients].

BACKGROUND: Hypotension after spinal anesthesia for cesarean section is common and may result in serious complications despite the use of uterine displacement and volume preloading. Adequate amount of hyperbaric bupivacaine for Japanese parturients whose frames are generally smaller than those of Caucasian counterparts have not yet been examined. We compared the analgesic efficacy and the incidence of hypotension with 8 mg versus 10 mg hyperbaric bupivacaine during spinal anesthesia for cesarean section in Japanese parturients. METHODS: Thirty six parturients were randomly divided into two groups, one receiving 8 mg (n = 19) and the other receiving 10 mg (n = 17) hyperbaric bupivacaine. Sensory block level and the incidence of hypotension were evaluated from the time of injection to delivery. Hypotension was defined as a decrease in systolic blood pressure below 100 mmHg and to less than 80% of the baseline value. RESULTS: 15 minutes after spinal injection, the difference in sensory block level was not significant. Ten minutes after the spinal anesthesia, in 79% of 8 mg group and in 88% of 10 mg group, sensory block level reached T 4. Hypotension occurred in 19 parturients (7 in 8 mg group and 12 in 10 mg group). The incidence of hypotension was significantly lower in 8 mg group (37%) than in 10 mg group (71%). There were no significant differences either in neonatal Apgar scores or umbilical blood gas pH. CONCLUSIONS: Injection of 8 mg hyperbaric bupivacaine is preferable than 10 mg in spinal anesthesia for cesarean section to obtain adequate analgesic efficacy and to avoid maternal hypotension.

[Vocal cord palsy after the use of a laryngeal mask airway].

A 58-year-old woman underwent oophorectomy for an ovarian tumor. Anesthesia was maintained with epidural block, and propofol and fentanyl anesthesia using a laryngeal mask airway. After the operation, she complained of hoarseness and difficulty in swallowing. Right vocal cord palsy was found by a ENT surgeon. The condition returned to normal two months after the operation. We have to have in mind that vocal cord palsy may occur even if we use a laryngeal mask airway. At least we have to pay attention to intra-cuff pressures and the position of the laryngeal mask airway.