Incidence of anesthesia-related medication errors over a 15-year period in a university hospital

Fukuoka Igaku Zasshi. 2008 Mar;99(3):58-66.


To clarify the incidence of anesthesia-related medication errors in Kyushu University Hospital, a retrospective analysis of anesthesia-related incidents from 1993 to 2007 was conducted based on the "Investigation of anesthesia-related medication incidents" by the Japanese Society of Anesthesiologists. Out of a total of 64,285 anesthesia cases, drug errors occurred in 50 cases (0.078%), but none of the incidents led to serious sequelae. Wrong medication was the most common type of drug error (48%), followed by overdose (38%), underdose (4%), omission (2%), and incorrect administration route (8%). The most commonly involved drugs were opioids, cardiac stimulants, and vasopressors. Syringe swap was the leading cause of wrong medication, accounting for 42%, drug ampoule swap occurred in 33%, and the wrong choice of drug was made in 17%. The first, second, and third most frequent causes of overdose involved a misunderstanding or preconception of the dose (53%), pump misuse (21%), and dilution error (5%). The error frequency did not decrease over the 15-year period. The responsible anesthesiologists were most likely to be doctors with a little experience. To reduce anesthesia-related medication errors, improvements of protocols for handling medication and instruction, and an improved education system for the anesthesia trainees are essential.

MeSH terms

  • Analgesics, Opioid / administration & dosage
  • Analgesics, Opioid / adverse effects
  • Anesthesia / statistics & numerical data*
  • Anesthesiology / education
  • Anesthetics / administration & dosage*
  • Anesthetics / adverse effects
  • Cardiotonic Agents / administration & dosage
  • Cardiotonic Agents / adverse effects
  • Clinical Competence
  • Drug Overdose / epidemiology
  • Hospitals, University / statistics & numerical data*
  • Humans
  • Incidence
  • Japan / epidemiology
  • Medication Errors / prevention & control
  • Medication Errors / statistics & numerical data*
  • Retrospective Studies
  • Time Factors


  • Analgesics, Opioid
  • Anesthetics
  • Cardiotonic Agents