EditordDrug errors are defined as any unintended patient safety incident relating to the handling of drugs that could have led, or did lead, to harm. They are the most frequent critical incidents in anaesthesia. 1 Whilst in adults approximately one-third of errors lead to harm, life-threatening errors are even more likely in paediatric anaesthesia. This is because of variable exposure of some anaesthetists to paediatric patients, age and weight variations, and the potential for large-scale errors. 2 The Paediatric Anaesthesia Trainee Research Network conducted a tablet device survey amongst anaesthetists attending the 2017 Association of Paediatric Anaesthetists of Great Britain and Ireland Annual Scientific Meeting. This evaluated the frequency of drug errors, reporting attitudes, and potential avenues for improvement. Of 354 delegates, there were 162 respondents (46%). They ranged in grade from core trainee (n¼4) to consultant (n¼99; 61%) with an approximate 50:50 split amongst those with more or less than five years of paediatric anaesthetic experience. A total of 60% of anaesthetists experienced paediatric drug errors at least once every year, 15% of whom reported experiencing an error at least once every month. These frequencies are likely to underestimate true frequencies because of reluctance to self-report errors and failure of error recognition. Calculation and dilution errors accounted for half of all errors. This was followed by the i.v. cannula not being flushed (16%) and wrong drug administration (11%). In order of frequency, antibiotics, opioids, paracetamol, and neuromuscular blocking agents were the most commonly involved drugs. The most common causative factors were distractions and interruptions whilst handling drugs, dose or dilution miscalculations, and anaesthetist fatigue. Amongst reporting attitudes, 36% of respondents stated that they would only report errors resulting in actual patient 4. Kaufmann J, Roth B, Engelhardt T, et al. Development and prospective federal statewide evaluation of a device for height-based dose recommendations in prehospital pediatric emergencies: a simple tool to prevent most severe drug errors.
Bispectral index (BIS) is a monitoring modality designed and used for monitoring depth of anaesthesia. We wish to report a case where BIS monitoring may have alerted us to a potential adverse neurological event during angiographic coiling of a cerebral aneurysm.
Bispectral index (BIS) is a monitoring modality designed and used for monitoring depth of anaesthesia. We wish to report a case where BIS monitoring may have alerted us to a potential adverse neurological event during angiographic coiling of a cerebral aneurysm.
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