A Multi-Disciplinary Narrative Review: Medication Safety in the Surgical Patient from Prescription to Administration
Abstract
Background: Medication errors in surgical patients represent a critical, multifaceted threat to patient safety, occurring at any point in a complex, multi-handler pathway. The unique perioperative environment, involving high-stakes pharmacology and numerous handoffs between diverse professionals, creates distinct vulnerabilities. Aim: This narrative review aims to synthesize contemporary evidence (2010-2024) on the epidemiology of medication errors in surgical care and to trace the medication-use process across the interconnected disciplines involved, identifying systemic risks and collaborative strategies for mitigation. Methods: A comprehensive literature search was conducted across PubMed, CINAHL, Scopus, and Web of Science databases. Results: Errors are prevalent, with high-risk points at prescribing (especially antimicrobials and analgesics), transcription/communication, anaesthesia administration, and post-operative monitoring. Fragmented systems, ambiguous communication, and role overload are key contributors. Evidence supports structured interventions like computerised physician order entry with decision support, standardised handoff protocols, barcode-assisted medication administration, and enhanced interdisciplinary training (e.g., simulation, crew resource management) as effective in reducing errors. Successful implementation is fundamentally dependent on strong health services administration policies and a pervasive culture of safety. Conclusion: Medication safety in surgery is an inherently interdisciplinary challenge. A "siloed" approach is ineffective. Future strategies must be architected around integrated care pathways, leveraging health information technology and fostering a culture of shared responsibility from the executive suite to the bedside, involving every link in the chain from the medical secretary to the resident doctor and surgical team.
Full text article
References
Argo, A., Zerbo, S., Lanzarone, A., Buscemi, R., Roccuzzo, R., & Karch, S. B. (2019). Perioperative and anesthetic deaths: toxicological and medico legal aspects. Egyptian Journal of Forensic Sciences, 9(1), 20. https://doi.org/10.1186/s41935-019-0126-6
Balch, A., Wendelboe, A. M., Vesely, S. K., & Bratzler, D. W. (2017). Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile. PLoS One, 12(6), e0179117. https://doi.org/10.1371/journal.pone.0179117
Barnsteiner, J. H. (2008). Medication reconciliation. Patient safety and quality: an evidence-based handbook for nurses.
Bates, D. W., & Singh, H. (2018). Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Affairs, 37(11), 1736-1743. https://doi.org/10.1377/hlthaff.2018.0738
Borycki, E., Dexheimer, J. W., Cossio, C. H. L., Gong, Y., Jensen, S., Kaipio, J., ... & Takeda, H. (2016). Methods for addressing technology-induced errors: the current state. Yearbook of medical informatics, 25(01), 30-40. DOI: 10.15265/IY-2016-029
Bratzler, D. W., Dellinger, E. P., Olsen, K. M., Perl, T. M., Auwaerter, P. G., Bolon, M. K., ... & Weinstein, R. A. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American journal of health-system pharmacy, 70(3), 195-283. https://doi.org/10.2146/ajhp120568
Coiera, E., Ash, J., & Berg, M. (2016). The unintended consequences of health information technology revisited. Yearbook of medical informatics, 25(01), 163-169. DOI: 10.15265/IY-2016-014
Cresswell, K., Williams, R., & Sheikh, A. (2021). Using cloud technology in health care during the COVID-19 pandemic. The Lancet Digital Health, 3(1), e4-e5. https://doi.org/10.1016/S2589-7500(20)30291-0
Dejos, M. C. (2021). Medication safety and medication error prevention. In Remington (pp. 749-758). Academic Press. https://doi.org/10.1016/B978-0-12-820007-0.00039-8
Duffy, C. C., Bass, G. A., Duncan, J., Lyons, B., & O’Dea, A. (2022). Medication Errors in Anesthesiology: Is It Time to Train by Example? Vignettes Can Assess Error Awareness, Assessment of Harm, Disclosure, and Reporting Practices. Journal of Patient Safety, 18(1), 16-25. DOI: 10.1097/PTS.0000000000000785
Ferreira, A. L. C. G., & Souza, A. I. (2021). The role of telehealth in sexual and reproductive health services in the response to COVID-19. Revista Brasileira de Saúde Materno Infantil, 21, 319-322. https://doi.org/10.1590/1806-9304202100S100019
Foslien-Nash, C., & Reed, B. (2020). Just culture is not “just” culture—It’s shifting mindset. Military medicine, 185(Supplement_3), 52-57. https://doi.org/10.1093/milmed/usaa143
Gjeraa, K., Spanager, L., Konge, L., Petersen, R. H., & Østergaard, D. (2016). Non-technical skills in minimally invasive surgery teams: a systematic review. Surgical endoscopy, 30(12), 5185-5199. https://doi.org/10.1007/s00464-016-4890-1
Harolds, J. A. (2022). Quality and safety in healthcare, part LXXXIV: using patient safety culture surveys to improve high reliability organizations. Clinical Nuclear Medicine, 47(12), e767-e769. DOI: 10.1097/RLU.0000000000003481
Harrison, M. I., Koppel, R., & Bar-Lev, S. (2007). Unintended consequences of information technologies in health care—an interactive sociotechnical analysis. Journal of the American medical informatics Association, 14(5), 542-549. https://doi.org/10.1197/jamia.M2384
Isherwood, P., & Waterson, P. (2021). To err is system; a comparison of methodologies for the investigation of adverse outcomes in healthcare. Journal of Patient Safety and Risk Management, 26(2), 64-73. https://doi.org/10.1177/2516043521990261
Krämer, I., Goelz, R., Gille, C., Härtel, C., Müller, R., Orlikowsky, T., ... & Exner, M. (2023). Good handling practice of parenterally administered medicines in neonatal intensive care units–position paper of an interdisciplinary working group. GMS Hygiene and Infection Control, 18, Doc10. https://doi.org/10.3205/dgkh000436
Middleton, B., Sittig, D. F., & Wright, A. (2016). Clinical decision support: a 25 year retrospective and a 25 year vision. Yearbook of medical informatics, 25(S 01), S103-S116. DOI: 10.15265/IYS-2016-s034
Mitchell, I., Schuster, A., Smith, K., Pronovost, P., & Wu, A. (2016). Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ quality & safety, 25(2), 92-99.
Mrusek, B., Miller, M., & Olaganathan, R. (2020, March). Shared leadership and just culture: Tools to promote SMS hazard reporting. In 2020 IEEE Aerospace Conference (pp. 1-13). IEEE. https://doi.org/10.1109/AERO47225.2020.9172531
Petrucci, E., Vittori, A., Cascella, M., Vergallo, A., Fiore, G., Luciani, A., ... & Marinangeli, F. (2021, August). Litigation in anesthesia and intensive care units: an Italian Retrospective Study. In Healthcare (Vol. 9, No. 8, p. 1012). MDPI. https://doi.org/10.3390/healthcare9081012
Riman, K. A., Harrison, J. M., Sloane, D. M., & McHugh, M. D. (2023). Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction. Nursing research, 72(1), 20-29. DOI: 10.1097/NNR.0000000000000626
Sculli, G. L., Pendley-Louis, R., Neily, J., Anderson, T. M., Isaacks, D. B., Knowles, R., ... & Gunnar, W. (2022). A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. Journal of patient safety, 18(1), 64-70. DOI: 10.1097/PTS.0000000000000788
Stone, E. G. (2018). Unintended adverse consequences of a clinical decision support system: two cases. Journal of the American Medical Informatics Association, 25(5), 564-567. https://doi.org/10.1093/jamia/ocx096
Tanner, C., Gans, D., White, J., Nath, R., & Pohl, J. (2015). Electronic health records and patient safety. Applied clinical informatics, 6(01), 136-147. DOI: 10.4338/ACI-2014-11-RA-0099
Tawfik, D. S., Adair, K. C., Palassof, S., Sexton, J. B., Levoy, E., Frankel, A., ... & Profit, J. (2023). Leadership behavior associations with domains of safety culture, engagement, and health care worker well-being. The Joint Commission Journal on Quality and Patient Safety, 49(3), 156-165. https://doi.org/10.1016/j.jcjq.2022.12.006
Urman, R. D., August, D. A., Chung, S., Jiddou, A. H., Buckley, C., Fields, K. G., ... & Raemer, D. (2021). The effect of emergency manuals on team performance during two different simulated perioperative crises: a prospective, randomized controlled trial. Journal of clinical anesthesia, 68, 110080. https://doi.org/10.1016/j.jclinane.2020.110080
Villemure, C., Georgescu, L. M., Tanoubi, I., Dubé, J. N., Chiocchio, F., & Houle, J. (2019). Examining perceptions from in situ simulation-based training on interprofessional collaboration during crisis event management in post-anesthesia care. Journal of Interprofessional Care, 33(2), 182-189. https://doi.org/10.1080/13561820.2018.1538103
Wildenbos, G. A., Peute, L. W., & Jaspers, M. W. M. (2016). Impact of patient-centered eHealth applications on patient outcomes: a review on the mediating influence of human factor issues. Yearbook of medical informatics, 25(01), 113-119.
Wright, A., Ai, A., Ash, J., Wiesen, J. F., Hickman, T. T. T., Aaron, S., ... & Sittig, D. F. (2018). Clinical decision support alert malfunctions: analysis and empirically derived taxonomy. Journal of the American Medical Informatics Association, 25(5), 496-506. https://doi.org/10.1093/jamia/ocx106
Wu, D. T., Barrick, L., Ozkaynak, M., Blondon, K., & Zheng, K. (2022). Principles for designing and developing a workflow monitoring tool to enable and enhance clinical workflow automation. Applied Clinical Informatics, 13(01), 132-138. DOI: 10.1055/s-0041-1741480
Authors
Copyright (c) 2024 Mubarak Mohammed Jamaan Aljamaeen, Ali Mohammad Ali Ageeli, Waad Abdulelah Alobaidy, Abdulmalik Gharbi Ayis Alshammari, Salihah Abdullah Saeed Alghamd, Abdulmajid Maneh Matar Alharbi, Njod Ahmed Ghmari, Ahmed Hameed Alharbi, Hashem Ahmed Junid, Maryam Mohammed Harthi, Reem Makmi Khideer Albanaqy, Akram Abdullah H. Tarmookh
This work is licensed under a Creative Commons Attribution 4.0 International License.