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

Labuschagne, M. T.; Robbetze, W; Rozmiarek, J; Strydom, Marianna; Wentzel, Mari; Diedericks, B J S; Joubert, G

doi:10.7196/samj.4556

Cited by 14 publications

(24 citation statements)

References 11 publications

(19 reference statements)

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“…trainees) Self-report anonymous questionnaire Self-report anonymous questionnaire—no further detail given Self-report by anaesthesiologists Self-report by anaesthesiologists Reid-Searl et al [ 63 ] Nursing students Semi-structured individual interviews Semi-structured individual interviews Nurse researcher Nurse researcher Kim et al [ 85 ] Nurses (incl. Senior roles) Self-report using questionnaire survey Self-report using questionnaire survey—multiple choice contributing factors selected Nurses self-report: questionnaire survey Nurses self-report: questionnaire survey Labuschagne et al [ 70 ] Various grade of doctor administering anaesthesia Self-report survey questionnaire Self-report questionnaire survey—identify one or more factors associated with error(s) Self-reported using questionnaire survey Self-reported using questionnaire survey Ozkan et al [ 88 ] Nurses DO DO and semi-structured interview using critical incident technique Nurse student observer Nurse student observer and researcher (interviewer) Agalu et al [ 84 ] Nurses DO and chart review DO and chart review Nurse and pharmacist data collectors Nurse and pharmacist data collectors Colligan and Bass [ 59 ] Nurses DO, simulation exercises and semi-structured interviews Semi-structured interviews and simulation NS interviewer NS interviewer Gill et al [ …”

Section: Resultsmentioning

confidence: 99%

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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Section: Resultsmentioning

confidence: 99%

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

et al. 2013

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“…48 The literature shows that the inappropriate labelling of medication is a cause of medication administration errors in general 26,27 and in anaesthetic practice. [28][29][30] Labelling recommendations for medication containers include colourcoded labels for different medication classes, patient name, patient hospital number, name of medication added to the container, amount of medication added, total volume of diluent in container, concentration of solution, date and time solution was prepared, signature of healthcare workers who prepared and checked the solution, and route of administration. 25,49 In our study the name of the solution was indicated on all 110 (100%) containers from which samples were collected.…”

Section: Resultsmentioning

confidence: 99%

“…25 Inappropriate labelling of medication has been identified as a cause for medication administration errors in general 26,27 and in anaesthetic practice. [28][29][30] Anaesthetists can be held legally accountable for medication administration errors and the administration of contaminated medication. 31 Common practice at Chris Hani Baragwanath Academic Hospital (CHBAH) is to use boluses of a self-prepared phenylephrine solution (referred to as the solution) to treat hypotension, due to the vasodilatory effects of a spinal anaesthetic, in stable patients undergoing a Caesarean section.…”

mentioning

confidence: 99%

Microbial contamination and labelling of self-prepared, multi-dose phenylephrine solutions used at a teaching hospital

Heever

Scribante

Perrie

et al. 2016

Southern African Journal of Anaesthesia and Analgesia

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Background: Common practice at Chris Hani Baragwanath Academic Hospital (CHBAH) is to use boluses from a self-prepared, multi-dose phenylephrine solution to treat spinal anaesthesia-induced hypotension in patients undergoing a Caesarean section. The aims of this study were to determine if there was microbial contamination of the solutions and to evaluate whether healthcare workers adhered to appropriate labelling and aspiration practices. Methods: A sample was collected and the labelling data were documented from the solutions found in the two obstetric theatres at CHBAH over a three-month period. The samples were sent to a laboratory for microbial investigation. Results: Microbial contamination was identified in 6.4% of samples collected. The name of the solution was indicated on 100% of the containers and the concentration of the solution was on 96.4%. The date the solution was prepared was indicated on 74.6% of containers and the time the solution was prepared was on 57.3%. Only 8.2% of healthcare workers who prepared the solution confirmed it by placing a signature on the container. Labelling data were written directly on 100% of the containers and a spikedevice was used in 64.5% of the containers. Conclusions: This study demonstrated microbial contamination of the solution and may indicate an infection hazard. Healthcare workers also did not adhere to appropriate labelling and aspiration practices. This is important for all patients from a patient safety perspective and the need to improve quality of care.

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“…Specific coloursare being use to differentiate anaesthetic medication according to an agreed national standard. [22,24] Other factors that have been highlighted as possible causes of medication error in anaesthetic practice include fatigue and distraction. Effort should be made by all stakeholders to ensure that the anaesthetic practice setting across Africa be made as convenient and comfortable as possible with adequate power, ventilation and lightening.…”

Section: Discussionmentioning

confidence: 99%

Medication Administration Error in Anaesthetic Practice: AReview of the African Experience

Rotimi¹,

Aleku²,

Obamiro³

et al. 2014

IOSRJPBS

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

Cited by 14 publications

References 11 publications

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

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

Microbial contamination and labelling of self-prepared, multi-dose phenylephrine solutions used at a teaching hospital

Medication Administration Error in Anaesthetic Practice: AReview of the African Experience

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