Evidence-based strategies for preventing drug administration errors during anaesthesia

Can sugammadex save a patient in a simulated 'cannot intubate, cannot ventilate' situation?

Recent studies have shown that the use of high dose rocuronium followed by sugammadex provides a faster time to recovery from neuromuscular blockade following rapid sequence induction than suxamethonium. In a manikin-based 'cannot intubate, cannot ventilate' simulation, we studied the total time taken for anaesthetic teams to prepare and administer sugammadex from the time of their initial decision to use the drug. The mean (SD) total time to administration of sugammadex was 6.7 (1.5) min, following which a further 2.2 min (giving a total 8.9 min) should be allowed to achieve a train-of-four ratio of 0.9. Four (22%) teams gave the correct dose, 10 (56%) teams gave a dose that was lower than recommended, four (22%) teams gave a dose that was higher than recommended, six (33%) teams administered sugammadex in a single dose, and 12 (67%) teams gave multiple doses. Our simulation highlights that sugammadex might not have saved this patient in a 'cannot intubate, cannot ventilate' situation, and that difficulties and delays were encountered when identifying, preparing and administering the correct drug dose.

Sequential drug verification errors resulting in wrong drug administration during caesarean section

An intravenous bolus of phentolamine was inadvertently given to a parturient during an emergency caesarean section following delivery of her infant when the intention had been to give an intravenous bolus of 5 IU Syntocinon. Root cause analysis identified a series of errors originating in the hospital pharmacy when one drug package was mistakenly issued in place of another. Subsequent checks failed to detect the original mistake. The final and most important check immediately before intravenous administration was also at fault. This case highlights a systems failure that permitted issue, transportation and administration of the wrong drug to a parturient. Robust measures to ensure avoidance of drug administration errors should be evaluated and introduced where possible.

Merits of using color and shape differentiation to improve the speed and accuracy of drug strength identification on over-the-counter medicines by laypeople

OBJECTIVE

This study aimed to examine the utility of using color and shape to differentiate drug strength information on over-the-counter medicine packages. Medication errors are an important threat to patient safety, and confusions between drug strengths are a significant source of medication error.

METHOD

A visual search paradigm required laypeople to search for medicine packages of a particular strength from among distracter packages of different strengths, and measures of reaction time and error were recorded.

RESULTS

Using color to differentiate drug strength information conferred an advantage on search times and accuracy. Shape differentiation did not improve search times and had only a weak effect on search accuracy.

CONCLUSIONS

Using color to differentiate drug strength information improves drug strength identification performance. Color differentiation of drug strength information may be a useful way of reducing medication errors and improving patient safety.

Medication error in anaesthesia and critical care: A cause for concern

Medication error is a major cause of morbidity and mortality in medical profession, and anaesthesia and critical care are no exception to it. Man, medicine, machine and modus operandi are the main contributory factors to it. In this review, incidence, types, risk factors and preventive measures of the medication errors are discussed in detail.

Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study

A safety-orientated system of delivering parenteral anaesthetic drugs was assessed in a prospective incident monitoring study at two hospitals. Anaesthetists completed an incident form for every anaesthetic, indicating if an incident occurred. Case mix data were collected and the number of drug administrations made during procedures estimated. From February 1998 at Hospital A and from June 1999 at Hospital B, until November 2003, 74,478 anaesthetics were included, for which 59,273 incident forms were returned (a 79.6% response rate). Fewer parenteral drug errors occurred with the new system than with conventional methods (58 errors in an estimated 183,852 drug administrations (0.032%, 95% CI 0.024-0.041%) vs 268 in 550,105 (0.049%, 95% CI 0.043-0.055%) respectively, p = 0.002), a relative reduction of 35% (difference 0.017%, 95% CI 0.006-0.028%). No major adverse outcomes from these errors were reported with the new system while 11 (0.002%) were reported with conventional methods (p = 0.055). We conclude that targeted system re-design can reduce medical error.

Drug administration errors: a prospective survey from three South African teaching hospitals

This prospective study was undertaken to determine the incidence of drug administration errors by anaesthetists at three tertiary South African hospitals. Hospitals A and C treat adults predominantly, whereas Hospital B is a paediatric hospital. Anaesthetists completed an anonymous study form for every anaesthetic performed over a six-month period. They were asked to indicate whether or not an error or near-miss had occurred and if so, the details thereof. A total of 30,412 anaesthetics were administered during the study period. The response rate and combined incidence of errors and near-misses was as follows: Hospital A 48.8% (1:320), B 81.3% (1:252) and C 48.1% (1:250). The overall response rate was 53% and the combined incidence was 1:274. Neither the experience of the anaesthetist nor emergency surgery influenced whether an error occurred or not. Most errors occurred during the maintenance phase of anaesthesia. The most common errors were those of substitution. At the paediatric hospital, incorrect dose was as frequent an error as substitution. Of all errors, 36.9% were due to drug ampoule misidentification; of these the majority (64.4%) were due to similar looking ampoules. Another 21.3% were due to syringe identification errors. No major complication attributable to a drug administration error was reported. Despite an increasing awareness of the problem together with suggestions in the literature to reduce the incidence, drug administration errors remain fairly common in South Africa. Failure to institute suggested solutions will continue to compromise patient safety.

[Syringe drug labels: a French national survey]

INTRODUCTION

The French Society of Anaesthesiology (SFAR) recommends the use of pre printed self-stick syringe labels. However, French anaesthesia-syringe labelling customs is yet unknown.

STUDY DESIGN

Therefore, a national phone survey was performed in order to investigate this issue.

RESULTS

Forty-five percent of the answering centers (324/722) used colour self-stick labels, with a larger proportion in public centers and a large regional variability. The kind of colour code differed from an area to another. Among centers using colour labels, the international recommended colour code was used in only 36% of them. The majority of health care providers declare to be favourable to the use of the colour self-stick labels and the standardization of the colour code as well. A relationship between the University hospital and the surrounded area has been observed for the use of the colour labels and the choice of the colour code.

CONCLUSION

Colour labels are used in France by nearly half of the centers, but international colour code is less spread.

Medication errors in the PACU

A collaborative research group examined seven years of PACU medication errors from the MEDMARX database. Descriptive statistics showed a comparison of medication errors in all ages from pediatric to adult to geriatric groups. Nine categories of medication errors were noted and a total of 3,023 errors were attributed to errors in prescribing, transcribing, dispensing, administering, and monitoring. Harmful errors were present in 5.8% of the sample, which included two patient deaths. Results indicated that errors can occur in any age group. Organizations and institutions should be aware of these occurrences to ensure vigilance at all times and to focus efforts toward avoiding or decreasing such errors. Patient safety and error prevention recommendations are provided.

A new infusion syringe label system designed to reduce task complexity during drug preparation

A new safety-orientated drug infusion label was studied and was compared with conventional methods by prospectively collecting incident reports from November 1998 to November 2003. Anaesthetists were asked to return an incident form for every anaesthetic (87% response rate), the vast majority indicating that no error had occurred. One error was reported with the use of the new label. However, this was due to an incorrect patient weight being recorded in the notes, and the dose was correct for the information available. Therefore, this data point was not included in the analysis. Seven errors were reported in the calculation of dosage using conventional infusion labels during 18 491 anaesthetics compared with no calculation errors in 10 655 anaesthetics with the new label (p = 0.045, Chi-squared test). Despite the difficulties of demonstrating significant benefit from safety initiatives in medicine, these data suggest that targeted system redesign can be effective inreducing error.

Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia

A 51-year-old patient scheduled for surgery under general anaesthesia was accidentally given remifentanil 150 microg and propofol 1% 10 ml through an intracerebroventricular totally implantable access port placed in the right infraclavicular region, which was mistakenly thought to be an intravenous line. Severe pain in the head and neck caused the mistake to be discovered rapidly, and 20 ml of a mixture of cerebrospinal fluid and the anaesthetic drugs were aspirated from the implantable access port. The patient suffered no apparent adverse neurological sequelae.

Considering the impact of medicine label design characteristics on patient safety

Medication errors involving patients receiving the wrong medicines, the wrong dosages or failure to take medicines according to the prescribed schedule are a substantial threat to patient safety. In the medical domain, research evidence on the benefits of improved labelling are piecemeal and often single-product or single-manufacturer driven and often do not inform the more general process of label design. Government and other guidelines on this topic are often low level and non-specific, often failing to give evidence-based guidance. However, there is a wealth of evidence-based research findings in related areas such as food labelling, chemical labelling and more general warnings research, which can provide systematic evidence on the effects of design characteristics such as font size, colour, signal words and linguistic usage on crucial performance variables such as compliance, understandability and discriminability. This research is reviewed and its relevance to medicine labelling is presented.

High latent drug administration error rates associated with the introduction of the international colour coding syringe labelling system 1

BACKGROUND AND OBJECTIVES

The potential for increased drug administration errors during the transition to the International Colour Coding syringe labelling system has been highlighted. The purpose of this study was to assess the potential effects before their introduction into our department.

METHODS

Thirty-one anaesthetists, 19 with no previous practical experience of the new labelling system (Group 1), and 12 with previous experience (Group 2), volunteered to induce general anaesthesia for a standardized simulated patient in a designated theatre. They were presented with a scenario designed to suggest the need for a rapid sequence induction and provided with drug syringes labelled with the International Colour Coding system. All drug administrations were recorded. Active error was defined as the injection of the wrong drug. Latent error was defined as the selection of a syringe in error but stopping short of administering the drug.

RESULTS

In Group 1 a total of 107 drug injections were recorded of which 1 (0.9%) was an active error and 16 (15%) involved latent errors. Eleven anaesthetists (58%) performed at least one latent error. Group 2 had an error rate of 3%, a 6.9 (1.3-26.7) fold reduction in the rate of error (P = 0.023).

CONCLUSIONS

Although only one drug was given in active error, latent errors occurred in 15% of drug administrations. The only factor conferring protection against error was prior experience of the new labelling system. The period of transition to the International Colour Coding syringe labelling system represents a time of increased risk of drug administration error.

The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals

Safety practices in health care have not kept pace with the increasing complexity of medical technology. Although anaesthesia is generally considered to be a leader in the improvement of patient safety, more powerful safety strategies must be found and employed. From an analysis of system characteristics, the nuclear power industry is proposed as an alternative analogy for safety in anaesthesia, and a novel diagrammatic approach is developed for the conceptualisation of safety goals. The nuclear power industry has spent vastly more time and money than has health care on the development of safety, and has progressed through significant safety milestones approximately three times more quickly than has anaesthesia. The greatest scope for the improvement of safety in anaesthesia lies in the appropriate re-design of medical systems and the lowering of the threshold for the reporting of incidents to include accident precursors, thus allowing the identification of dangerous systems before accidents occur.

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error

We present two reports of pregnant women in labor who inadvertently received a magnesium sulfate solution in their epidural space. Both women received approximately 9 mg of magnesium sulfate, and neither of them demonstrated any signs or symptoms of focal neurological toxicity. Once the mistakes were discovered and appropriate medication was delivered, the patients attained an acceptable level of analgesia.

Radiopharmaceutical maladministrations in New South Wales

BACKGROUND

Errors in medicine are being increasingly highlighted. There is potential for harm in nuclear medicine.

AIM

To evaluate the frequency, type, causes and adverse effects of nuclear medicine radiopharmaceutical maladministrations reported to the New South Wales Environment Protection Authority.

METHODS

We reviewed reports received by the New South Wales Environment Protection Authority over a 5-year period. The number and type of maladministrations, contributing factors and any adverse effects were recorded. Comparison was made with the total number of medicare-paid diagnostic and therapeutic nuclear medicine services undertaken in New South Wales for the same period.

RESULTS

Fifty-seven maladministrations were reported to the New South Wales Environment Protection Authority. There were 666 179 nuclear medicine procedures recorded in New South Wales for the same period. Of the 57 reported maladministrations, the majority (n=34; 61%) were a result of incorrect radiopharmaceutical dispensing. Incorrect reading of labels attached to the syringe (n=8; 14%) and incorrect patient identification (n=7; 12%) accounted for most of the rest of the accidents. Most (n=48; 84%) involved 99mTc-based radiopharmaceuticals for diagnostic use, with three cases involving I for therapeutic use. In 96% of cases - those which involved diagnostic radiopharmaceuticals - there were no immediate adverse clinical outcomes. However, one subject developed unintended hypothyroidism as a result of the maladministration of 131I for therapy.

CONCLUSION

Nuclear medicine maladministrations in New South Wales are uncommon, with approximately 8-9 incidents per 100 000 procedures. Most maladministrations are the consequence of incorrect radiopharmaceutical dispensing. All those which involved diagnostic radiopharmaceuticals resulted in no immediate adverse effects from the radiation exposure.

Medication errors in anaesthesia and critical care

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.

Drug related critical incidents

Drug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect/drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.