Drug Administration Errors by South African Anaesthetists—a Survey

Gordon, P C; Llewellyn, R L; James, M. F. M.

doi:10.1080/22201173.2006.10872432

Cited by 28 publications

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“…The questionnaire used by Gordon et al 2 was modified for this investigation. It required doctors to provide information including: (i) demographic information on respondents, (ii) information regarding the administration of anaesthesia, (iii) reporting of errors, and (iv) the occurrence of errors during anaesthesia.…”

Section: Methodsmentioning

confidence: 99%

“…In addition to 66 errors, 45 near-misses were reported. 6 Gordon et al 2 found that fatigue and distraction played a role in 14.1% and 4.7% of errors, respectively, while 10.6% of errors in another study 6 could be attributed to the respondent taking medication at the time of the error. Adverse events from errors included hypertension, hypotension, cardiac arrest, tachycardia, bradycardia, prolonged paralysis, and awareness under anaesthesia.…”

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confidence: 99%

“…Erroneous administration of drugs causes unnecessary harm to patients, and is especially relevant in anaesthesia as potent intravenous agents are frequently injected. 2,3 Their effects may be of no clinical significance, result in minor morbidity requiring immediate intervention to prevent permanent injury, or major morbidity (e.g. cardiac arrest, stroke or permanent injury or death) as the main or contributory cause.…”

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confidence: 99%

“…Adverse events from errors included hypertension, hypotension, cardiac arrest, tachycardia, bradycardia, prolonged paralysis, and awareness under anaesthesia. 2 Doctors in South African hospitals with limited resources and large numbers of patients are often subjected to adverse factors contributing to system, equipment and human errors, which may cause stress and burnout and increase errors in the administration of anaesthesia medication. [7][8][9] We investigated the occurrence of such events in public sector hospitals in the Free State province, that included full-time practising anaesthetists and many doctors who occasionally administer anaesthesia.…”

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confidence: 99%

“…5 Of a total of 329 reported anaesthesia errors, 136 (41.3%) were human errors, of which 17.6% were knowledge-, 27.9% skill-and 25.7% rule-based, and 6.6% were technical errors. 5 Most anaesthetists in South Africa will administer an erroneous drug at some stage, 2 of which a few may lead to severe patient morbidity or death. A large study 6 of more than 30 000 anaesthetics administered by specialist and/or trainee anaesthetists found that 36.9% of errors were due to misidentification of drug ampoules, 64.4% of which could be attributed to ampoules having a similar appearance.…”

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confidence: 99%

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Errors in drug administration by anaesthetists in public hospitals in the Free State

et al. 2011

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confidence: 99%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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Errors in drug administration by anaesthetists in public hospitals in the Free State

et al. 2011

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Standardised drug labelling in intensive care: results of an international survey among ESICM members

et al. 2012

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Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

et al. 2013

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BackgroundUnderlying systems factors have been seen to be crucial contributors to the occurrence of medication errors. By understanding the causes of these errors, the most appropriate interventions can be designed and implemented to minimise their occurrence.ObjectiveThis study aimed to systematically review and appraise empirical evidence relating to the causes of medication administration errors (MAEs) in hospital settings.Data SourcesNine electronic databases (MEDLINE, EMBASE, International Pharmaceutical Abstracts, ASSIA, PsycINFO, British Nursing Index, CINAHL, Health Management Information Consortium and Social Science Citations Index) were searched between 1985 and May 2013.Study SelectionInclusion and exclusion criteria were applied to identify eligible publications through title analysis followed by abstract and then full text examination. English language publications reporting empirical data on causes of MAEs were included. Reference lists of included articles and relevant review papers were hand searched for additional studies. Studies were excluded if they did not report data on specific MAEs, used accounts from individuals not directly involved in the MAE concerned or were presented as conference abstracts with insufficient detail.Data Appraisal and Synthesis MethodsA total of 54 unique studies were included. Causes of MAEs were categorised according to Reason’s model of accident causation. Studies were assessed to determine relevance to the research question and how likely the results were to reflect the potential underlying causes of MAEs based on the method(s) used.ResultsSlips and lapses were the most commonly reported unsafe acts, followed by knowledge-based mistakes and deliberate violations. Error-provoking conditions influencing administration errors included inadequate written communication (prescriptions, documentation, transcription), problems with medicines supply and storage (pharmacy dispensing errors and ward stock management), high perceived workload, problems with ward-based equipment (access, functionality), patient factors (availability, acuity), staff health status (fatigue, stress) and interruptions/distractions during drug administration. Few studies sought to determine the causes of intravenous MAEs. A number of latent pathway conditions were less well explored, including local working culture and high-level managerial decisions. Causes were often described superficially; this may be related to the use of quantitative surveys and observation methods in many studies, limited use of established error causation frameworks to analyse data and a predominant focus on issues other than the causes of MAEs among studies.LimitationsAs only English language publications were included, some relevant studies may have been missed.ConclusionsLimited evidence from studies included in this systematic review suggests that MAEs are influenced by multiple systems factors, but if and how these arise and interconnect to lead to errors remains to be fully determined. Further research with a theoret...

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Drug Administration Errors by South African Anaesthetists—a Survey

Cited by 28 publications

References 0 publications

Errors in drug administration by anaesthetists in public hospitals in the Free State

Errors in drug administration by anaesthetists in public hospitals in the Free State

Standardised drug labelling in intensive care: results of an international survey among ESICM members

Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

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