Anest. intenziv. Med. 2026;37(2):72-77 | DOI: 10.36290/aim.2026.016

Failure of safety barriers in the prevention of medication errors in perioperative careOriginal Article

Fišera V.¹, Vojtíšek P.², Novotný T.³

¹ Úsek ředitele UL - manažer kvality, Krajská zdravotní, a. s. - Masarykova nemocnice v Ústí nad Labem, o. z.

² Klinika anesteziologie, perioperační a intenzivní medicíny, Fakulta zdravotnických studií Univerzity J. E. Purkyně v Ústí nad Labem a Krajská zdravotní, a. s. - Masarykova nemocnice v Ústí nad Labem, o. z.

³ Ortopedická klinika, Fakulta zdravotnických studií Univerzity J. E. Purkyně v Ústí nad Labem a Krajská zdravotní, a. s. - Masarykova nemocnice v Ústí nad Labem, o. z.

Medication errors represent a significant cause of preventable patient harm in perioperative care, particularly in the pediatric population, where the risk of dosing errors is increased due to weight-based dose calculations, variability in drug concentrations, and a limited tolerance to dosing deviations. Although standardized safety procedures, including the surgical safety checklist of the World Health Organization, have been implemented, their effectiveness in preventing pharmacotherapy-related errors remains uncertain.

Objective: To assess the functionality of perioperative safety barriers in the prevention of medication errors based on a systematic analysis of a real adverse event and to compare these findings with available literature. Study design: Retrospective system-based quality analysis combined with a targeted literature review.

Material and methods: A serious medication error involving a pediatric patient was analyzed using root cause analysis conducted by an independent multidisciplinary hospital quality management team. The findings were compared with published evidence focusing on human factors and safety barriers in perioperative care.

Results: The analysis demonstrated that critical safety barriers may fail despite formal adherence to the perioperative safety process. The absence of structured verification of drug dose, units, and concentration, lack of closed-loop communication, and failure to perform independent verification before drug administration were identified as key contributing factors.

Conclusion: The medication error primarily reflected a failure of the system of safety barriers rather than an individual mistake. Effective prevention requires a targeted redesign of perioperative safety processes with systematic integration of pharmacotherapy control.

Keywords: medication errors, perioperative care, patient safety, surgical safety checklist, root cause analysis, human factors.

Received: February 11, 2026; Revised: March 30, 2026; Accepted: April 20, 2026; Prepublished online: June 8, 2026; Published: July 10, 2026  Show citation