An observational feasibility study of a new anaesthesia drug storage tray

Abstract

Drug errors in the anaesthetic domain remain a serious cause of iatrogenic harm. To help reduce this issue, we explored the potential safety impact of using a simple colour-coded tray for anaesthetic drug preparation and storage. Over a six-month period, three different trained researchers observed 30 cases at three NHS Trusts. Ten observations involved standard drug trays in 'normal' practice, and 20 observations, involved 'Rainbow trays' before and after their introduction. We conducted 20 semi-structured interviews immediately after completing the Rainbow tray observation with the anaesthetists involved. All discussions and detailed notes taken were transcribed, qualitatively analysed using line-by-line coding and then synthesised into narrative themes. We found that using standard, single compartment trays enabled quick, cheap, and portable drug preparation and storage, but was linked to potential or actual harmful errors, such as syringe swaps. Rainbow trays were perceived to be easy to use and effective at all three sites, aiding drug identification and separation, and hence likely to reduce drug error and increase patient safety. We have demonstrated that it is feasible to introduce a new colour-coded compartmentalised Rainbow drugs tray into clinical practice at three NHS hospitals in England. Further research is needed into their effect on the prevalence of drug error.

A Qualitative Exploration of Consultant Anaesthetists Attitudes to, and Experiences of, Perioperative Medication Errors in Emergency and Elective Theatre Settings

“…29% of errors occurred due to a lack of a re-check prior to administration. Almghairbi, et al [13], devised a 'rainbow tray' that utilised a colour-coding schema for medicines. This was found to be an effective and low-cost method for organising work trays containing medication.…”

Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue

“…). Translated into practice, an error might be mitigated by keeping anaesthetic recipes simple, or discarding half‐used syringes or drugs that are unlikely to be needed from the drug tray . In this way, the model does lead to a testable hypothesis that describes how error rates increase with more ‘complex’ long anaesthetics involving multiple drugs and routes of injection.…”

‘Humanware’: the human in the system

“…For instance, one could estimate the effect of reducing the number of drugs available during an operation, or one could reduce the number of accessible injection routes. With increasing sophistication, one could also ‘test’ the effects of font size, bright lighting, prefilled syringes, circadian attention cycles, shifts, caffeine and sleep, and so on .…”