Drug Administration Errors: A Prospective Survey from three South African Teaching Hospitals

Abstract

Errors in medical practice are not uncommon and may contribute significantly to health care costs and result in harm to patients 1. The risk of serious drug errors in anaesthesia may be higher than other specialties 2. This is hardly surprising, considering that the average anaesthetist administers at least a quarter of a million drugs during a practice lifetime 3. The reported incidence of drug error during anaesthesia varies considerably from 1:133 (0.75%) to 1:5475 (0.02%) 4-7. Differences in study design and data collection may account for some of this discrepancy. Limited data exist for South Africa 8,9. This prospective study was undertaken to determine the incidence of drug administration errors and near-misses at three tertiary-care hospitals in South Africa. Hospitals A and C had predominantly adult patients and Hospital B was a specialist paediatric hospital. MATERIALS AND METHODS The study was approved by the Ethics Committees of the universities to which the hospitals were affiliated. Anaesthetists were asked to complete a study form for every anaesthetic performed during a six-month period. They were asked to indicate whether a drug administration error or near-miss (an incident with * M.B., Ch.B.

Evaluation of Perioperative Medication Errors and Adverse Drug Events

“…3 However, the literature on perioperative ME rates is sparse and contains largely self-reported data, 4-7 consisting of either spontaneous self-reports of errors 5, 7 or facilitated incident reporting of whether or not an error occurred. 1, 6 The validity and reliability of studies based on self-reporting of MEs in other patient care areas has been called into question. 8-10 For example, in a study of 2,557 doses of medications administered on hospital wards, Flynn and colleagues found 456 medication errors by direct observation, 34 by chart review and only one by self-report.…”

Patient safety in drug label design: analysis of reported adverse events before and after introducing a new label design

“…It has not been possible to identify a single conclusive explanation for this increase, but analyses of the medication error reports implicating epinephrine indicate a general challenge when administering drugs in ampoules. Look-alike confusion is a type of medication error often reported, particularly when administering drugs in ampoules 2 19. It is therefore possible that further initiatives beyond optimisation of the label are needed for this group of drugs.…”

Medication Errors in Anesthesia

“…19 The most commonly used reporting system for medication errors (MEDMARX) 20 was established by US Pharmacopeia, which is a national database collected from 422 voluntarily participating health care systems. [2][3][4]10,11 The top factors cited as leading to medication errors have remained relatively consistent for 22 years (Table 4). 20 Over a 7-year period from 1998 to 2005, >11,200 errors were reported.…”