Correspondence  |   August 2016
Evaluation of Perioperative Medication Errors
Author Notes
  • University of Washington, Seattle, Washington (T.A.B.). bowdle@u.washington.edu
  • (Accepted for publication April 20, 2016.)
    (Accepted for publication April 20, 2016.)×
Article Information
Correspondence
Correspondence   |   August 2016
Evaluation of Perioperative Medication Errors
Anesthesiology 8 2016, Vol.125, 429-431. doi:10.1097/ALN.0000000000001185
Anesthesiology 8 2016, Vol.125, 429-431. doi:10.1097/ALN.0000000000001185
The recent article by Nanji et al.1  concerning errors related to anesthetic drug administration is interesting and raises a number of provocative questions. However, we are concerned that the manner in which the data are presented and interpreted may lead readers to conclusions that may not be warranted.
Nanji et al. have utilized a very broad definition of drug administration error. For example, “significant hypotension (mean arterial pressure < 55 mmHg) that is not treated”1  is listed as a drug error in table 2. We would argue that depending upon the circumstances, this is not an error of drug administration (it may be an error in anesthetic management) and may not be an error at all. We would also argue that an unattended syringe of hydromorphone (table 5) is a not a drug administration error, although it may be a violation of a hospital policy for handling controlled substances. The authors have given other examples of their definitions of drug administration error but have not provided a complete list of all drug error definitions or a list of the errors observed in this study. Thus, it is difficult to know what was actually measured. This is important because their reported rate of error is at least an order of magnitude greater than reported by other investigators.
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