An anaesthetic drug error: minimizing the risk

Abstract

A medication error caused a near fatal cardiac arrest in a previously healthy patient undergoing elective surgery. Inadvertent epinephrine injection induced ventricular dysrhythmias, hypertension, hypotension and pulmonary oedema. The case was investigated using critical-incident technique and was reviewed by the Risk Management Team of the Department of Anaesthesia. The purpose of this report is to present the recommendations resulting from the investigation. These include: improved resident training in intravenous drug management, the use of anaesthetic drug ampoules with distinct labels, and the development of a standardized colour code system for labels on anaesthetic drug ampoules. Furthermore, it is recommended that all anaesthetic drug errors be reported to the Canadian agencies responsible for drug packaging in order to identify patterns in anaesthetic drug errors, and to facilitate the implementation of effective drug identification systems.

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

“…Of the general anesthesia errors two occurred during preparation for anesthesia, 39 during induction, nine during maintenance, and six during emergence. Fifty-six of the drug errors occurred during the day (08-16), six during the evening (16)(17)(18)(19)(20)(21)(22)(23)(24), and one during the night (00-08).…”

“…6,13,17,32 Standardisation can be done by the selection of drugs in the department, by defining drug preparation routines, and by the layout of drug trolleys. National standardisation of syringe labels were recommended by Radhakrishna, as he found a great variation in colour coding between hospitals in UK.…”

“…The addition of colour to a label is thought to be an additional visual and psychological cue for choosing the right ampoule or syringe. [16][17][18][19] The effect of 'colour coding' has not been tested, and has been challenged. 20 The aim of our study was to describe the frequency and pattern of drug errors in clinical anesthesia.…”

Medikamentų Ir Švirkštų Žymėjimas Anesteziologijoje

“…Klaidos, susijusios su vaistų skyrimu, yra ypač aktualios anesteziologijoje -medicinos šakoje, kuri reikalauja nuolatinio darbo su stipriai veikiančiais, įvairioms skirtingoms farmakologinėms grupėms priklausančiais medikamentais, kurių skyrimo klaida gali nulemti labai sudėtingas ir skaudžias pasekmes. Anksčiau publikuotuose užsienio straipsniuose pateiktų analizių duomenys teigia, jog dažniausios klaidos anesteziologijoje yra susijusios su medikamentų ampulių ar švirkštų sumaišymu, o pagal atliktos anoniminės apklausos duomenis net 30 procentų anesteziologų teigia per savo gydytojo praktikos metus bent kartą suklydę ir suleidę netinkamą vaistą (5). Suprantama, jog siekiant išvengti tokių medikamentų skyrimo klaidų svarbu gydytojo anesteziologo dėmesingumas ir susikaupimas, tačiau ne mažiau aktualu yra medikamentų ir švirkštų žymėjimo taktikos parinkimas ir tobulinimas siekiant bent kiek sumažinti klaidų, susijusių su vaistų sumaišymu, skaičių.…”

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

“…Readers interested in more comprehensive reviews of medication errors in anesthetic practice are referred to other articles 12,14 and recommendations. [14][15][16][17][18] Medication safety in anesthesia…”