A Survey of the Sequelae of Memorable Anaesthetic Drug Errors from the Anaesthetist'S Perspective

Abstract

Drug errors amongst anaesthetists are common. Although there has been previous work on the system factors involved with drug error, there has been little research on the sequelae of a drug error from the anaesthetist's perspective. To clarify this issue, we surveyed anaesthetists regarding their most memorable drug error to identify associated factors and personal sequelae regarding their professional practice after the event. An online survey was sent anonymously to 989 Australian and New Zealand College of Anaesthetists (ANZCA) Fellows in March 2016 and the results were collected over the following two months. There were 295 completed surveys (29.8% response). The majority of respondents were male consultants, aged over 45 years. Reported drug errors occurred most frequently during normal working hours, and the most common drugs involved were non-depolarising muscle relaxants. In 34% of the errors, another anaesthetist was present, and their presence was felt to have contributed in 40.7% of these cases. About 20% of respondents reported that they did not receive adequate support after the event. Sleep patterns were affected in 14.4% of respondents, although very few found that the error had affected their capacity to function at work. These findings suggest that memorable drug errors can be significant enough to have adverse sequelae to anaesthetists, even if no patient harm occurs.

Assessment of Medication Errors Among Anesthesia Clinicians in Saudi Arabia: A Cross-Sectional Survey Study

“…We also found that most respondents believed that medication errors had no specific time of occurrence. However, Amponash et al[ 22 ] identified more errors occurring during night shifts, and McCawley et al[ 18 ] and Erdmann et al[ 19 ] reported more errors occurring during daytime working hours. One of our key findings is that most respondents reported no patient harm resulting from medication errors, consistent with other studies.…”

“…[ 26 ] Clinicians feel embarrassed, guilty, or blamed after disclosing errors, which might stop them from reporting errors. [ 18 , 32 ]…”

“…Many studies presented similar results: Double-checking before withdrawing and administering medication was the most effective drug safety measure. [ 20 , 21 , 23 ] McCawley et al[ 18 ] found that in 84.4% of reported errors, a second clinician was unavailable to double-check. However, the two-person confirmation is limited, owing to difficulty ensuring the availability of a second clinician.…”

“…[26] Clinicians feel embarrassed, guilty, or blamed after disclosing errors, which might stop them from reporting errors. [18,32] Some of our respondents (10.3%) said their hospital did not have a reporting system. The lack of having a clear policy is a well-known barrier to reporting errors.…”

“…[14,15] Studies in anesthesia had reported a high frequency of medication errors worldwide. [1,[16][17][18][19][20][21][22][23] However, there is a lack of studies to address the occurrence of anesthetic medication errors in Saudi Arabia.…”