Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system

Abstract

Background: Anaesthetic medication administration errors are a significant threat to patient safety. In 2002, we began collecting data about the rate and nature of anaesthetic medication errors and implemented a variety of measures to reduce errors. Methods: Facilitated self-reporting of errors was carried out in 2002e2003. Subsequently, a medication safety bundle including 'smart' infusion pumps were implemented. During 2014 facilitated self-reporting commenced again. A barcodebased medication safety system was then implemented and the facilitated self-reporting was continued through 2015. Results: During 2002e2003, a total of 11 709 paper forms were returned. There were 73 reports of errors (0.62% of anaesthetics) and 27 reports of intercepted errors (0.23%). During 2014, 14 572 computerised forms were completed. There were 57 reports of errors (0.39%) and 11 reports of intercepted errors (0.075%). Errors associated with medication infusions were reduced in comparison with those recorded in 2002e2003 (P<0.001). The rate of syringe swap error was also reduced (P¼0.001). The reduction in error rate between 2002e2003 and 2014 was statistically significant (P¼0.0076 and P¼0.001 for errors and intercepted errors, respectively). From December 2014 through December 2015, 24 264 computerised forms were completed after implementation of a barcode-based medication safety system. There were 56 reports of errors (0.23%) and six reports of intercepted errors (0.025%). Vial swap errors in 2014e2015 were significantly reduced compared with those in 2014 (P¼0.004). The reduction in error rate after implementation of the barcode-based medication safety system was statistically significant (P¼0.0045 and P¼0.021 for errors and intercepted errors, respectively). Conclusions: Reforms intended to reduce medication errors were associated with substantial improvement.

Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system

“…16 For example, the implementation of a barcode-based system and a medication safety bundle can reduce self-reported errors and intercepted error rates. 17 These, and other human factors-driven system solutions such as prefilled syringes could help reduce the cognitive workload on anaesthesia providers and the possibility for medication errors. 18 Standardisation of medication concentrations and equipment, redesigning the clinical work space, 19 or using electronically controlled smart pumps with standardised concentrations are other effective, evidencebased recommendations.…”

Why we scan the barcodes of anaesthetic medications

“…The Codonics™ vial label barcode scanner and syringe label printer that we described in our article was associated with a reduced incidence of vial swap error. 1 It is important to note that our providers do not regard the Codonics machine as inefficient or as complicating their workflow. In fact, providers at the University of Washington Medical Center regard the Codonics machine as a labour-saving device that improves workflow.…”

“…EditordWhen intraoperative bronchospasm occurs in ventilated patients, initiating therapy without delay is necessary, including deepening of anaesthesia, optimisation of ventilation, and administration of a beta-2 agonist. 1,2 The clinical efficacy of beta-2 agonists administered with a pressurised metered-dose inhaler (pMDI) and a spacer chamber in the inspiratory limb of the ventilator circuit just before the Ypiece has been demonstrated, but there are no data concerning beta-2 agonists deposition. 3e5 In anaesthesia practice, the use of a spacer chamber is controversial, 1,2,6 probably because of a lack of data.…”

“…1,2 The clinical efficacy of beta-2 agonists administered with a pressurised metered-dose inhaler (pMDI) and a spacer chamber in the inspiratory limb of the ventilator circuit just before the Ypiece has been demonstrated, but there are no data concerning beta-2 agonists deposition. 3e5 In anaesthesia practice, the use of a spacer chamber is controversial, 1,2,6 probably because of a lack of data. Moreover, because of disposable ventilation circuits, it is not always possible to disconnect and place the spacer chamber as recommended.…”

Sustainable quality and safety improvement in healthcare: further lessons from the aviation industry

“…Pragmatically, a good evaluation of change over time can be achieved by continued collection of data under constant conditions with access to a reliable denominator in order to calculate error rates. 10,11 Many commercial airlines throughout the world use an alternative approach to continuous quality and safety improvement that could be practically applied to the complexities of healthcare, including the medication error problem. This is a system of activity monitoring called Flight Operational Quality Assurance (FOQA).…”