Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database

Abeysekera, A.; Bergman, Ivan; Kluger, M. T.; Short, Timothy G.

doi:10.1111/j.1365-2044.2005.04123.x

Cited by 173 publications

(131 citation statements)

References 45 publications

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“…[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. 8 Two prospective studies 1,9 and one retrospective study 4 have reported human factors contributing to medication errors/pre-errors during the conduct of anesthesia.…”

Section: Introductionmentioning

confidence: 99%

Influences observed on incidence and reporting of medication errors in anesthesia

Cooper

DiGiovanni

Schultz

et al. 2012

Can J Anesth/J Can Anesth

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Background Medication errors are a common occurrence during the conduct of anesthesia (one in 113-450 patients). Several factors contribute to medication errors in anesthesia, including experience of the anesthesia provider, severity of comorbidities, and type of procedure. The inexperience of anesthesia providers-in-training also leads to increased error rates. This prospective observational study repeats and extends previous work by Webster et al. and Llewellyn et al. examining the role of comorbidities, type of case, and level of provider experience on the incidence of medication errors. Methods After Institutional Review Board review and exemption from informed consent, medication error reporting forms were attached to every anesthetic record during a six-month period. All providers were asked to return the forms for every anesthetic, on a strictly voluntary and anonymous basis, and to record the occurrence of medication errors. If providers indicated that a medication error had occurred, additional details about the event were obtained anonymously. Results There were 8,777 (83%) responses obtained in a review of 10,574 case forms. A medication error was reported in 35 forms, with an additional 17 forms indicating a medication pre-error or near miss, resulting in 52 (0.49%) errors/pre-errors or a reported incidence of 1:203 anesthetics. Most case types were observed to have a statistically significant increase in reported medication errors. Reported errors by type of anesthesia provider were categorized into anesthesia provider-in-training group and the experienced provider group. The anesthesia providerin-training group reported a twofold increase in the rate of errors, with the most frequently reported errors being incorrect dose and substitution.

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Section: Introductionmentioning

confidence: 99%

Influences observed on incidence and reporting of medication errors in anesthesia

Cooper

DiGiovanni

Schultz

et al. 2012

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

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“…Whilst such serious outcomes should be rapidly disseminated and targeted for remedial action, they may be relatively infrequent even within a large organisation such as the NHS, and are greatly outnumbered by system failures without adverse outcome. The Australian Incident Monitoring System (AIMS), composed of a generic structure and additional systems owned by specialists in several areas (including anaesthetics), has led to a number of important developments in the understanding of safety and in the development of professional practice [6,7]. It has also been successful in prioritising interventions, developing an awareness of error, and reducing blame, with systems analysis a second-tier benefit [8].…”

mentioning

confidence: 99%

Safety in anaesthesia: a study of 12 606 reported incidents from the UK National Reporting and Learning System

2008

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SummaryThe incident reporting database at the National Patient Safety Agency was interrogated on the nature, frequency and severity of incidents related to anaesthesia. Of 12 606 reports over a 2-year period, 2842 (22.5%) resulted in little harm or a moderate degree of harm, and 269 (2.1%) resulted in severe harm or death, with procedure or treatment problems generating the highest risk. One thousand and thirty-five incidents (8%) related to pre-operative assessment, with harm occurring in 275 (26.6%), and 552 (4.4%) related to epidural anaesthesia, with harm reported in 198 (35.9%). Fifty-eight occurrences of anaesthetic awareness were also examined. This preliminary analysis is not authoritative enough to warrant widespread changes of practice, but justifies future collaborative approaches to reduce the potential for harm and improve the submission, collection and analysis of incident reports. Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility.

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“…This problem is often due to administration of an incorrect drug from a correctly labelled syringe. 11,13,20 Switching of look-alike drug ampoules and vials is also common. The drugs most frequently involved include neuromuscular blocking agents, inotropes, and opioids.…”

Section: Résumémentioning

confidence: 99%

“…The drugs most frequently involved include neuromuscular blocking agents, inotropes, and opioids. 11,13,20 Interestingly, many errors occur during the maintenance phases of anesthesia, possibly when the anesthesiologist's vigilance is low. The level of experience of the anesthesia care providers is another major contributing factor, given that the error rate is almost twice as high among trainees as among experienced anesthesiologists.…”

Section: Résumémentioning

confidence: 99%

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

Orser

Hyland²,

David³

et al. 2012

Can J Anesth/J Can Anesth

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Purpose This article presents a summary of recent advances, including tools and interventions, that are designed to improve drug safety for patients in critical care settings, particularly those undergoing anesthesia and surgery. Principal findings Medication error remains a leading cause of adverse events among patients undergoing anesthesia. Misidentification of ampoules, vials, and syringes is a common source of error. Systems are now being engineered to reduce the likelihood of medication misidentification through approaches such as revision of standards for labelling of drug ampoules and vials and the development of bar code systems that allow ''double checking'' or drug verification in the operating room. Also, efforts are being made to improve medication reconciliation, a process for accurately communicating a patient's medication information during transitions from one healthcare setting to another. Finally, the opportunity exists for anesthesiologists to increase awareness about the rising problem of opioid addiction in patients for whom typical doses are initially prescribed for appropriate indications such as postoperative pain. Conclusions There is a need to improve drug delivery systems in complex critical care environments, particularly the operating room. Anesthesiologists must continue to play a leading role in promoting drug safety in these environments.

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Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database

Cited by 173 publications

References 45 publications

Influences observed on incidence and reporting of medication errors in anesthesia

Influences observed on incidence and reporting of medication errors in anesthesia

Safety in anaesthesia: a study of 12 606 reported incidents from the UK National Reporting and Learning System

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

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