Correspondence  |   August 2016
Adverse Drug Events Link to Severity of the Event Data Needed
Author Notes
  • University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (J.W.I.). ibinsonjw@upmc.edu
  • (Accepted for publication April 20, 2016.)
    (Accepted for publication April 20, 2016.)×
Article Information
Correspondence
Correspondence   |   August 2016
Adverse Drug Events Link to Severity of the Event Data Needed
Anesthesiology 8 2016, Vol.125, 431. doi:10.1097/ALN.0000000000001186
Anesthesiology 8 2016, Vol.125, 431. doi:10.1097/ALN.0000000000001186
Although thought provoking and likely to lead to significant research in the future, the data presented by Nanji et al.1  are not sufficient to support a conclusion that medication errors (MEs) occurring during the course of anesthesia lead to meaningful harm. A primary concern is the tenuous link between MEs and adverse drug events (ADEs). Forty of 91 actual ADEs were not related to MEs and were considered “nonpreventable.” No tabulation of the harm caused by these events is given, and it is possible that most of the significant and life-threatening outcomes fell into this category. Of the remaining 51 ADEs, the Naranjo algorithm determined that only about half were “probably” related to the ME, and the other half were considered “possibly” or “doubtfully” due to the error. Thus, MEs may have caused or contributed to less than a third of the ADEs. The overall rate of 28 of 3,671 (0.8%) is considerably smaller than the undifferentiated error rate of 193 of 3,671 (5.3%) and ADE rate of 91 of 3,671 (2.5%) offered by the authors.
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