Making errors: admitting them and learning from them

Woods, Ian

doi:10.1111/j.1365-2044.2005.04149.x

Cited by 11 publications

(8 citation statements)

References 10 publications

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“…However, no such systematic innovations have yet been widely adopted to reduce medication error. It is impossible to address drug error effectively without addressing the organizational culture of anesthesia 9 . Many would regard it as a not acceptable practice in 2009 because new clean syringe should be used for every different drug or only one syringe for every drug.…”

Section: Discussionmentioning

confidence: 99%

Erros farmacológicos na prática anestésica: quatro casos de morbidades não fatais

Herrero¹,

Reina²,

Blasco³

et al. 2010

Rev. Bras. Anestesiol.

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Section: Discussionmentioning

confidence: 99%

Erros farmacológicos na prática anestésica: quatro casos de morbidades não fatais

Herrero¹,

Reina²,

Blasco³

et al. 2010

Rev. Bras. Anestesiol.

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“…Given that the location of a medication is one of the cues used to select ampoules, 2 standardizing the organization of medications in the anesthesia cart is only one of the recommendations frequently cited. [1][2][3][4][5][6][7] While no strategy will eliminate all errors completely, standardizing the medication drawer is expected to reduce selection errors and minimize the potential cognitive load from confusion and inefficient searching by healthcare professionals who work with randomly differing anesthesia cart configurations.…”

Section: Discussionmentioning

confidence: 99%

“…[3][4][5][6][7] Standardization forces consistency of use, one of the most basic principles of usability engineering. 8 The concept is relatively simple -items of information or objects should be consistently located in the same place to facilitate search, familiarity, and recognition.…”

Section: Résumémentioning

confidence: 99%

Standardizing anesthesia medication drawers using human factors and quality assurance methods

Shultz

Davies

Caird

et al. 2010

Can J Anesth/J Can Anesth

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Purpose In Calgary, each of the three acute-care adult hospitals had different anesthetic medication carts with their own type and layout of anesthetic medications. A number of anesthesiologists moved among the different sites, increasing the potential for medication errors. The objective of this study was to identify the anesthetic medications to include and to determine how they should be grouped and positioned in a standardized anesthesia medication cart drawer. Methods A standardized list of medications was established. Next, the anesthesia medication cart drawer was filled and photographed, and a jigsaw puzzle was made from the photograph. Anesthesiologists and anesthesia assistants arranged the jigsaw pieces into an ideal drawer. Participants verbalized their rationale for the position of each puzzle piece. Results were collated and analyzed. A mock drawer was developed and reviewed by department members, and minor modifications were made. Results A final standardized medication drawer (content and positioning) was developed over 30 months, with agreement from anesthesiologists (n = 12) and anesthesia assistants (n = 3) at the three hospitals. Guidelines for placing each medication in the drawer included grouping them according to order of use, frequency of use, similarity of action, severity of harm from misuse, and lack of similar appearance. A finalized template was used for a standardized drawer and installed in every operating room of the three hospitals. Conclusion Implementation of the standardized medication drawer is expected to reduce the likelihood of medication errors. Future research should include testing the clinical implications of this standardization and applying the methodology to other areas. A survey of Canadian anesthesiologists showed that 85% of participants had made at least one medication-related error or close call. Résumé1 Most frequently, these errors involved administering muscle relaxants rather than reversal agents, typically as a result of misidentified ampoules and vials or 'syringe swaps'. Also, survey respondents identified incorrectly stocked medications as one of the contributing factors. Almost two decades earlier, Currie et al. found a similar pattern of results in voluntarily submitted incident reports, and they suggested that erroneously injected medications were frequently administered from a correctly coded or labelled syringe (63% of the time).2 Moreover, these authors noted that one-fifth of ampoule selection errors occurred because the cue to select the 'correct' ampoule was its location. Once selected, the likelihood of detecting the 'incorrect' medication before it was administered was relatively low (42%).Not standardizing the location of medications can contribute to the increased likelihood of an anesthesiologist selecting the incorrect medication or another individual stocking the incorrect medication. Also, inconsistently placing medications contributes to inefficiency, for instance, anesthesiologists and other healthcare providers must spend ti...

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“…A persistent and concerning problem in anaesthesia is that of drug administration error, as highlighted in recent papers in this journal, including an in‐depth review [8–11]. Between 1978 (the year of Cooper et al.…”

Section: Prospective Estimates Of Rates Of Drug Administration Error mentioning

confidence: 99%

“…It is heartening therefore to read of the significant safety advances which have recently occurred involving the redesign of drug administration systems [10]. Despite being told as late as 2002 that there was ‘no realistic possibility of an “international” scheme’ for the colour‐coding of syringe labels [21], Britain has now adopted the ‘international’ colour standard used in the United States, Australia, New Zealand and Canada, and has done so without significant incident [22].…”

Section: Prospective Estimates Of Rates Of Drug Administration Error mentioning

confidence: 99%

The iatrogenic‐harm cost equation and new technology

Webster¹

2005

Anaesthesia

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Making errors: admitting them and learning from them

Cited by 11 publications

References 10 publications

Erros farmacológicos na prática anestésica: quatro casos de morbidades não fatais

Erros farmacológicos na prática anestésica: quatro casos de morbidades não fatais

Standardizing anesthesia medication drawers using human factors and quality assurance methods

The iatrogenic‐harm cost equation and new technology

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