Medication errors in anesthetic practice: a survey of 687 practitioners

Abstract

GENERAL ANESTHESIA 139 Purpose: The objectives of this study were to determine: 1) if anesthesiologists had experienced a medication error and 2) to identify causal factors. The perceived value of a Canadian reporting agency for medication errors and improved standards for labels on drug ampoules was also investigated. Methods: A self-reporting survey was mailed to members of the Canadian Anesthesiologists' Society (n = 2,266). Respondents provided free-text descriptions of medication errors and answered fixed response questions. Results: Surveys from 687 anesthesiologists (30% response rate) revealed that 85% of the participants had experienced at least one drug error or "near miss". Although most errors (1,038) were of minor consequence (98%), four deaths were reported. The commonest error involved the administration of muscle relaxants instead of a reversal agent. "Syringe swaps" (70.4%) and the misidentification of the label (46.8%) were common contributing factors. Anesthesiologists (97.9%) reported that they read the ampoule label "most of the time" although the label colour was an important secondary cue. Approximately half of the participants would report the error if a reporting program existed and 84% agreed that improved standards for drug labels would reduce the incidence of error. Conclusions: Most anesthesiologists experienced at least one drug error. The commonest error was a "syringe swap" that involved a muscle relaxant. Most errors were of minor consequence, however, serious morbidity and mortality resulted from clearly preventable events. These results support the development of improved standards for drug labels and the establishment of a Canadian reporting program for medication errors. Objectif : 1) Découvrir si les anesthésiologistes ont vécu l'expérience d'une erreur de médication et 2) en déterminer les facteurs de causalité. Aussi, on a étudié la valeur perçue d'une agence de notification canadienne des erreurs de médication et de normes strictes des étiquettes d'ampoules de médicaments. Méthode : Une enquête d'autodéclaration a été postée aux membres de la Société canadienne des anesthési-ologistes (n = 2,266). Les répondants ont fourni des descriptions en textes libres des erreurs de médication et ont répondu aux questions à réponses fixes. Résultats : Les réponses reçues de 687 anesthésiologistes (taux de réponse de 30 %) ont révélé que 85 % des participants avaient fait au moins une erreur de médicament ou l'avait évitée de justesse. Même si la plupart des erreurs (1,038) n'ont eu que des conséquences mineures (98 %), quatre décès ont été rapportés. L'erreur la plus fréquente concernait l'administration de myorelaxants à la place de décurarisants. "L'échange de seringue" (70,4 %) et la mauvaise identification de l'étiquette (46,8 %) étaient souvent des causes d'erreur. Certains (97,9 %) ont dit lire l'étiquette sur l'ampoule "la plupart du temps" même si la couleur de l'étiquette était un important signal sec-ondaire. La moitié des participants environ auraient mentionné l'erreur si...

Medication safety in anesthetic practice: first do no harm

“…Most anesthesiologists report being involved in at least one medication error. 5 Given so many opportunities for error and a system that provides few safeguards, it can be expected that medication errors in anesthesia will occur frequently. Perhaps it is more remarkable that there are not more catastrophic outcomes.…”

“…La plupart des anesthésiologistes ont rapporté avoir été impliqués au moins une fois dans une erreur de médication. 5 Étant donné les nombreuses occasions d'erreurs possibles et le peu de mesures de contrôle du système, on peut s'attendre que des erreurs de médi -cation anesthésique surviennent fréquemment. Peut-être est-il plus remarquable encore qu'il y ait aussi peu d'incidents catastrophiques.…”

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

“…[8][9][10][11][12] Fortunately, most anesthetic-related errors are inconsequential; however, some lead to substantial or permanent injury and even death. 8,13 In this review, we focus on systems designed to reduce medication errors in the operating room and highlight three Canadian initiatives: 1) systematic efforts to improve the labelling of drug ampoules and vials, 2) introduction of bar-coding in medication systems, and 3) novel tools for ''reconciliation'' or for accurate documentation and adjustment of patients' medication taken before and during their hospital stay. This article concludes with a description of emerging issues for drug safety in anesthesia.…”

“…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.…”

“…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.…”