Evidence map›Paper›PMID 26501385›Full record

Observational studyAnesthesiology2016

Evaluation of Perioperative Medication Errors and Adverse Drug Events.

Karen C Nanji, Amit Patel, Sofia Shaikh, Diane L Seger, David W Bates

2 registry-linked trialsAbstract readObservational Study
PubMed Full text at PMC Publisher
In one paragraph

Observational study in Anesthesiology, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 2 registered trials, which are not on this map. Cited by 71 papers, 3 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
71citing papers in PubMed, 3 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT04240301 not yet recruitingnot on this mapstarted 2026, after this paper: background citation

Global PRoMiSe (Perioperative Recommendations for Medication Safety): A Consensus-Based, Generalizable Approach

TypeobservationalSponsorKaren C. Nanji,M.D.,M.P.H.Ran2026 to 2026Enrolled120ConditionsPerioperative Medication Safety
NCT04342013 nanot yet recruitingnot on this mapstarted 2027, after this paper: background citation

Impact of a Novel Electronic Clinical Decision Support Application on Perioperative Medication Errors and Adverse Medication Events: a Randomized Controlled Trial

TypeinterventionalSponsorKaren C. Nanji,M.D.,M.P.H.Ran2027 to 2027Enrolled300ConditionsPerioperative Medication Errors, Perioperative Adverse Medication EventsArmsElectronic Clinical Decision Support Application
3 · Its place in the literature

Who cites it

71 citing papers in PubMed, 3 syntheses or guidelines pooled it.

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  17. High alert medications off the radar: A systematic review.Exploratory research in clinical and social pharmacy · 2025
    Review
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11 more citing papers are in PubMed but not listed here.

4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

5 authors.

Karen C NanjiFrom the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts (K.C.N., A.P., S.S.); Departments of Anesthesia (K.C.N.) and Medicine (D.W.B.), Harvard Medical School, Boston, Massachusetts; Partners Healthcare Systems, Inc., Wellesley, Massachusetts (K.C.N., D.L.S., D.W.B.); and Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (D.W.B.).
Amit Patel
Sofia Shaikh
Diane L Seger
David W Bates

Funding

Research Training for AnesthetistsT32GM007592 · NIGMS · MASSACHUSETTS GENERAL HOSPITAL · PI STUART A FORMAN · 1985 to 2026
$11.8M
NIGMS NIH HHS T32 GM007592NIGMS NIH HHS T32GM007592
6 · The paper itself

Abstract

backgroundThe purpose of this study is to assess the rates of perioperative medication errors (MEs) and adverse drug events (ADEs) as percentages of medication administrations, to evaluate their root causes, and to formulate targeted solutions to prevent them.

methodsIn this prospective observational study, anesthesia-trained study staff (anesthesiologists/nurse anesthetists) observed randomly selected operations at a 1,046-bed tertiary care academic medical center to identify MEs and ADEs over 8 months. Retrospective chart abstraction was performed to flag events that were missed by observation. All events subsequently underwent review by two independent reviewers. Primary outcomes were the incidence of MEs and ADEs.

resultsA total of 277 operations were observed with 3,671 medication administrations of which 193 (5.3%; 95% CI, 4.5 to 6.0) involved a ME and/or ADE. Of these, 153 (79.3%) were preventable and 40 (20.7%) were nonpreventable. The events included 153 (79.3%) errors and 91 (47.2%) ADEs. Although 32 (20.9%) of the errors had little potential for harm, 51 (33.3%) led to an observed ADE and an additional 70 (45.8%) had the potential for patient harm. Of the 153 errors, 99 (64.7%) were serious, 51 (33.3%) were significant, and 3 (2.0%) were life-threatening.

conclusionsOne in 20 perioperative medication administrations included an ME and/or ADE. More than one third of the MEs led to observed ADEs, and the remaining two thirds had the potential for harm. These rates are markedly higher than those reported by retrospective surveys. Specific solutions exist that have the potential to decrease the incidence of perioperative MEs.

Indexed as

AdultAgedAged, 80 and overDrug-Related Side Effects and Adverse ReactionsFemaleHumansMaleMedication ErrorsMiddle AgedPerioperative CareProspective StudiesRetrospective StudiesUnited StatesYoung Adult

Identifiers

PMID26501385
PMCPMC4681677

What OpenQuestion holds

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Registered trials

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.