Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina

Abstract

Most respondents committed more than one error in anesthesia administration, mainly justified as a distraction or fatigue, and of low gravity.

Why do Anesthesiologists Drug Administration Errors?

“…Yamamoto, et al [11] retrospectively analyzed an amount of (27454) anesthesia cases during previous 8 years, with only 61 administration errors, mainly overdose (25%), followed by substitution (23%) and omission (21%), also observed in another large prospective observational study, as incorrect dose (36.5%), substitution (25%) and omission (19.2%) [9]. Recent prospective study realized during 277 operations observed higher prevalence of labeling error (24.2%), followed by dose error (22.9%) and omission (17.6%) [3] that corroborates another recent study about one Brazilian State anesthesiologist's errors [1].…”

“…Errors like syringe swaps, drug ampoule swaps, overdose or incorrect drug choices were cited [10,11], but were also found more detailed as incorrect route (administration of a drug by another route), incorrect dose (unwanted concentration, amount or infusion rate), insertion (drug administered in unwanted time), replacement (administration of a drug different from the indented one), repetition (readministration of a drug due to prior administration uncertainty) and omission (a forgotten/nonadministered drug) [1].…”

“…The overall rate is observed in order of 4.87 errors per 100.000 administrations by pharmacists [2]. Anesthesiologists should attempt against errors because they represents the unique medical specialty that administrate the drug without another professional conference, easily acting as vectors of adverse events during anesthesia [1].…”

“…Other evaluated items were lack of knowledge or experience, unfamiliar vial or ampoule, inadequate communication among anesthesiologists, equipment malfunction, equipment not available and others [1,12]. Cooper, et al [13] cited factors with similar terms, but at most cases related to inadequate total experience.…”

“…Anesthesiologists should attempt against errors because they represents the unique medical specialty that administrate the drug without another professional conference, easily acting as vectors of adverse events during anesthesia [1]. Some factors expose more than others the susceptibility to undesirable events.…”