Adverse drug errors in anesthesia, and the impact of coloured syringe labels

Abstract

Purpose: To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors. Methods:We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed. Errors were divided into four groups: syringe swap, ampoule swap, other 'wrong drug' errors, and wrong dose errors. The problems were graded into four levels, according to severity.Results: A drug error was recorded in 63 cases (0.11%). There were 28 syringe swaps, and muscle relaxants were erroneously given in 15. There were nine ampoule swaps. There were eight 'other wrong drug' cases, and 18 cases where a wrong dose of the correct drug was given. Three of the drug errors were classified as serious, and 27 were of moderate severity. We found no differences between the two periods except for decreased number of ampoule swaps (P = 0.04).Conclusion: Drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps occurred most often between syringes of equal size, and were not eliminated by colour coding of labels. As muscle relaxant drugs are most commonly involved, and can cause lasting morbidity, special preventive measures should be taken for this group of drugs.Objectif: Décrire les erreurs de médicaments en anesthésie clinique selon leur fréquence et leur nature et éva-luer si une modification de la couleur des étiquettes codées des seringues pouvait, avec une certaine formation, résoudre ce problème. Conclusion : Les erreurs de médicaments sont rares et ne représentent qu'une petite partie des problèmes anesthésiques, mais elles sont toujours potentiellement dangereuses. Les échanges de seringues surviennent le plus souvent entre seringues de même taille et ils ne sont pas réduits par les étiquettes de couleurs codées. Les myorelaxants, le plus souvent en cause, peuvent entraîner une morbidité résiduelle. Des mesures préventives spéciales devaient être envisagées dans ce cas.

Influences observed on incidence and reporting of medication errors in anesthesia

“…[1][2][3][4][5] Complex surgical procedures and patients with significant comorbidities often require therapeutic interventions with infrequently used medications utilized under dynamic conditions, all contributing to higher medication error rates when compared with cases with lower surgical complexity. 6,7 The inexperience of trainees in the specialty may also lead to a higher frequency of medication errors in teaching programs, yet there are few data to support this claim.…”

“…Although Fasting and Gisvold reported that anesthesiologists have been involved in at least one medication error/ pre-error, most medication errors were deemed inconsequential. 5 Factors associated with medication errors/ pre-errors occurring within the operating room include personal distractions; production pressure; inadequate communication between medical caregivers; exposure to new, unexpected, or unfamiliar medication vials or labels; and misread/look-alike medication vials or ampules. 1,3,4,10 The aim of this prospective unblinded observational study was to determine whether the type of surgical case, the American Society of Anesthesiologists' (ASA) physical status classification, the level of experience of the anesthesia provider, or other factors impact the frequency and reporting of medication errors/pre-errors in a tertiary care academic teaching hospital.…”

Review article: Improving drug safety for patients undergoing anesthesia and surgery

“…6 The focus of this current review is on strategies that are currently being engineered into care delivery systems to reduce drug-related errors in anesthetic practice. Such errors, which occur at a rate of about 1 per 130-450 patients, [7][8][9][10][11] are associated with increases in morbidity, mortality, and the costs of hospital care. [8][9][10][11][12] Fortunately, most anesthetic-related errors are inconsequential; however, some lead to substantial or permanent injury and even death.…”

“…Such errors, which occur at a rate of about 1 per 130-450 patients, [7][8][9][10][11] are associated with increases in morbidity, mortality, and the costs of hospital care. [8][9][10][11][12] Fortunately, most anesthetic-related errors are inconsequential; however, some lead to substantial or permanent injury and even death. 8,13 In this review, we focus on systems designed to reduce medication errors in the operating room and highlight three Canadian initiatives: 1) systematic efforts to improve the labelling of drug ampoules and vials, 2) introduction of bar-coding in medication systems, and 3) novel tools for ''reconciliation'' or for accurate documentation and adjustment of patients' medication taken before and during their hospital stay.…”

“…10,21 The Canadian Standards Association (CSA) developed the first Canadian standard for labelling of drug ampoules, vials, and prefilled syringes, building on previous work by the Canadian Society of Hospital Pharmacists and input from Health Canada. B,C The CSA standard is designed to complement Health Canada regulations and guidance for labelling of pharmaceuticals.…”