The frequency and nature of drug administration error during anaesthesia

Noisiness in operating theatres: nurses' perceptions and potential difficulty communicating

Elevated operating theatre noise can be hazardous to patient safety and may cause occupational stress. In a nine-hospital study, background noise and average noise were measured, during operations in different subspecialties, and found to be higher than noise levels recommended by the World Health Organization (WHO) for hospital areas in which patient care takes place. In operations in which nurses had also answered a question about hearing 'quiet', 'normal', and 'loud' talking, speech interference levels were estimated and indicated that nurses and other personnel had to substantially raise their voices to be well understood.

Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital

PURPOSE

The Japanese Society of Anesthesiologists (JSA) has investigated critical events in several fields of anesthesiology. However, the types, frequency, and characteristics of medication errors related to anesthesia have not been investigated. By analyzing incident reports retrospectively, we investigated medication errors that occurred during anesthetic practice over the past 8 years at our institution.

METHODS

Incident reports related to medication errors that occurred between May 1999 and March 2007 were analyzed retrospectively using a questionnaire published by the JSA in the "Survey of medication errors related to anesthesia". During these 8 years, 233 incidents were reported, in a total of 27454 anesthesia cases conducted during this period. Of these incidents, 61 (26.2%) were anesthetic drug administration errors. In these 61 incidents, clerical error (e.g., erroneous prescription writing), and pre-error (defined as any incident with the potential to become an error) were excluded from the analysis. Consequently, 13 incidents were excluded and 48 incidents were analyzed.

RESULTS

Medication errors due to overdose were the most frequent kind of error (25%), followed by substitution (23%), and omission (21%). Errors due to an incorrect route of administration were rare. The drugs most frequently involved in these errors were antibiotics and muscle relaxants. Most of the patients involved in the incidents were, fortunately, not harmed seriously. The total frequency of medication errors in the survey period was 0.175% (48 incidents in 27 454 total anesthesia cases).

CONCLUSION

We found that overdose, substitution, and omission were the main causes of anesthesia-related medication errors in our department.

[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.

Critical incident monitoring in anaesthesia

PURPOSE OF REVIEW

Updates on developments in critical incident monitoring in anaesthesia, and assesses its role in improving patient safety.

RECENT FINDINGS

Critical incident reporting has become more widely accepted as an effective way to improve anaesthetic safety, and has continued to highlight the importance of human errors and system failures. The establishment of an international database also improves critical incident reporting. Experiences from the national reporting and learning system in the UK have provided some solutions to the many problems and criticisms faced by the critical incident reporting technique. Direct observations to detect errors are more accurate than voluntary reporting of critical incidents, and may be a promising new approach.

SUMMARY

Critical incident monitoring is a valuable tool in ensuring patient safety due to its low cost and the ability to provide a comprehensive body of detailed qualitative information. The qualitative information gathered can be used to develop strategies to prevent and manage existing problems, as well as to plan further initiatives for patient safety. Novel approaches should complement existing methods to achieve better results. The development of a culture which emphasises safety should go hand in hand with current audit activities.

Malpractice issues in modern anaesthesiology

Medical malpractice has been raised as an important problem in daily practice, while the media and public remain unforgiving to those perceived to have harmed the patients' life. This article highlights important legal issues related to medical malpractice and summarizes the sources and the nature of potential errors in anaesthesiology practice.

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.

Using system analysis to build a safety culture: improving the reliability of epidural analgesia

BACKGROUND

A potentially dangerous situation was revealed by an incident report describing the use of an inappropriate device to administer post-operative epidural analgesia to a patient on a surgical ward. The incident occurred in a 1200-bed university affiliated tertiary hospital (Geneva University Hospitals, HUG) and involved three clinical departments: anaesthesiology, the surgical intensive care unit and urology.

METHODS

A multidisciplinary system analysis was carried out to identify care-delivery problems and contributory factors. Corrective actions were devised on the basis of their ability to prevent and absorb unsafe situations.

RESULTS

The system analysis identified three care-delivery problems in relation to the management of epidural analgesia. It enabled medical and nursing managers to adopt an interdepartmental set of corrective actions: a common protocol for post-operative epidural analgesia, leading to the exclusive use of patient-controlled epidural analgesia (PCEA) pumps; greater availability of the patient-controlled pumps; the dissemination of guidelines; permanent proactive training of nurses by the acute-pain team; the clarification of medical responsibilities; and a common help-line phone number for all surgical departments.

DISCUSSION

The analysis provided a convincing exposure of various care-delivery problems and their corresponding contributory factors, as well as an opportunity to address a systemic issue in a multidisciplinary way. By thus facilitating decisions and corrective actions, the analysis was instrumental in strengthening our safety culture.

Human factors in pediatric anesthesia incidents

BACKGROUND

Anesthesia and the operating theater environment is a complex system involving man-machine and human-human interactions. Although we strive for an error free system, we are humans and errors and mistakes will occur. The aim of this study was to investigate the human factors behind events and incidents in pediatric anesthesia at our institution.

METHODS

This study consisted of a retrospective review and analysis of all contemporaneously reported anesthetic incidents between April 1, 2002 and March 31, 2004 at Birmingham Children's Hospital. Where there were anesthetic human factors involved in the event these were classified.

RESULTS

There were 668 incidents reported, giving a rate of 2.4% of the 28 023 anesthetics recorded. Airway and respiratory incidents were the most common representing 52.2% of all incidents. A total of 284 anesthetic human factors could be identified and classified. Of these the most common were errors in judgment 43%, failure to check 17.8%, technical failures of skill 9.2%, inexperience 7.7%, inattention/distraction 5.6% and communication issues 5.6%.

CONCLUSIONS

In our institution anesthetic human factors occur in 42.5% of in-theater incidents in pediatric anesthesia. Knowledge of these is necessary so that changes can be made in practice both by individuals and departments of anesthesia, to make anesthesia as safe as possible.

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.

Drug delivery as control task: improving performance in a common anesthetic task

OBJECTIVE

To conceptualize delivery of anesthesia as a control task, similar to control tasks in nonmedical domains, and to evaluate how presentation of new information and feedback affects task performance.

BACKGROUND

In anesthesia, integrated monitors that show intravenous drug and effect-site concentrations in a patient currently do not exist. However, using real-time displays of intravenous anesthetic concentrations and effects could significantly enhance intraoperative clinical performance. Pharmacological models are available to estimate past, present, and future drug concentrations in the brain and to predict the drug's physiological effects. A display that integrates pharmacological models and visualizes drug concentrations was developed and tested to see if this drug display significantly improved clinical performance.

METHOD

Thirty-three anesthesiologists with different levels of expertise administered anesthesia to simulated patients in a high-fidelity patient simulator. The experimental group used a drug display that visualized drug concentrations in real time, whereas the control group administered drugs without this information.

RESULTS

Anesthesiologists using the drug display achieved better hemodynamic control of the simulated patient than did the control group. Similarly, the drug display enabled anesthesiologists to wake up and reanimate the patient faster.

CONCLUSION

Visual feedback of drug concentrations leads to superior performance in the delivery of anesthesia. Drug delivery can be conceptualized within a control theoretical framework. Finally, the drug display has significant clinical potential to increase patient safety.

APPLICATION

Clinical performance in delivering anesthesia depends on feedback. By providing this feedback, the drug display supports clinicians' ability to more precisely and safely administer anesthesia.

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.

Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database

Eight hundred and ninety-six incidents relating to drug error were reported to the Australian Incident Monitoring Study. Syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labelled but given in error, and 187 (20.8%) due to selection of the wrong ampoule or drug labelling errors. The drugs most commonly involved were neuromuscular blocking agents, followed by opioids. Equipment misuse or malfunction accounted for a further 234 (26.1%) incidents; incorrect route of administration 126 (14.1%) incidents; and communication error 35 (3.9%) incidents. The outcomes of these events included minor morbidity in 105 (11.7%), major morbidity in 42 (4.7%), death in three (0.3%) and awareness under anaesthesia in 40 (4.4%) incidents. Contributing factors included inattention, haste, drug labelling error, communication failure and fatigue. Factors minimising the events were prior experience and training, rechecking equipment and monitors capable of detecting the incident. The information gained suggests areas where improved guidelines are required to reduce the incidence of drug error. Further research is required into the effectiveness of preventive strategies.

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.

Use of incident reports by physicians and nurses to document medical errors in pediatric patients

OBJECTIVES

To describe the proportion and types of medical errors that are stated to be reported via incident report systems by physicians and nurses who care for pediatric patients and to determine attitudes about potential interventions for increasing error reports.

METHODS

A survey on use of incident reports to document medical errors was sent to a random sample of 200 physicians and nurses at a large children's hospital. Items on the survey included proportion of medical errors that were reported, reasons for underreporting medical errors, and attitudes about potential interventions for increasing error reports. In addition, the survey contained scenarios about hypothetical medical errors; the physicians and nurses were asked how likely they were to report each of the events described. Differences in use of incident reports for documenting medical errors between nurses and physicians were assessed with chi(2) tests. Logistic regression was used to determine the association between health care profession type and likelihood of reporting medical errors.

RESULTS

A total of 140 surveys were returned, including 74 from physicians and 66 by nurses. Overall, 34.8% of respondents indicated that they had reported <20% of their perceived medical errors in the previous 12 months, and 32.6% had reported <40% of perceived errors committed by colleagues. After controlling for potentially confounding variables, nurses were significantly more likely to report >or=80% of their own medical errors than physicians (odds ratio: 2.8; 95% confidence interval: 1.3-6.0). Commonly listed reasons for underreporting included lack of certainty about what is considered an error (indicated by 40.7% of respondents) and concerns about implicating others (37%). Potential interventions that would lead to increased reporting included education about which errors should be reported (listed by 65.4% of respondents), feedback on a regular basis about the errors reported (63.8%) and about individual events (51.2%), evidence of system changes because of reports of errors (55.4%), and an electronic format for reports (44.9%). Although virtually all respondents would likely report a 10-fold overdose of morphine leading to respiratory depression in a child, only 31.7% would report an event in which a supply of breast milk is inadvertently connected to a venous catheter but is discovered before any breast milk goes into the catheter.

CONCLUSIONS

Medical errors in pediatric patients are significantly underreported in incident report systems, particularly by physicians. Some types of errors are less likely to be reported than others. Information in incident reports is not a representative sample of errors committed in a children's hospital. Specific changes in the incident report system could lead to more reporting by physicians and nurses who care for pediatric patients.

Inadvertent epidural injection of ephedrine in labor

Drugs mistakenly administered into the epidural space can have serious neurologic sequelae. This case reports the inadvertent administration of ephedrine during labor in a 17-year-old woman. The possible complications for both the mother and fetus are discussed and compared with other published literature reports.

Evidence-based strategies for preventing drug administration errors during anaesthesia

We developed evidence-based recommendations for the minimisation of errors in intravenous drug administration in anaesthesia from a systematic review of the literature that identified 98 relevant references (14 with experimental designs or incident reports and 19 with reports of cases or case series). We validated the recommendations using reports of drug errors collected in a previous study. One general and five specific strong recommendations were generated: systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.

A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods

Fifteen anaesthetists were observed while providing anaesthesia for 15 pairs of adult cardiac surgical operations, using conventional methods for one of each pair and a new drug administration system designed to reduce error for the other. Aspects of each method were rated by users on 10-cm visual analogue scales (10 being best). The new system was rated more favourably than conventional methods in terms of safety (median [range] = 8.1 [6.8-9.7] vs. 7.1 [2.6-9.3] cm; p = 0.001) and usability (8.5 [5.9-9.4] vs. 7.5 [3.2-9.8] cm; p=0.027). The new system saved preparation time both before anaesthesia (median [range] = 180 [32-480] vs. 360 [120-600] s; p=0.013) and during anaesthesia (10 [2-38] vs. 12 [10-60] s; p=0.009). Prefilled syringes for the new system increased costs by euro 23.00 per anaesthetic (p = 0.041), but this increase is likely to be offset by the potential of the new system to decrease costly iatrogenic harm by preventing drug error.

Drug errors in obstetric anaesthesia: a national survey

We conducted a postal survey of lead obstetric anaesthetists in all consultant-led maternity units in the UK about drug errors and the measures taken to reduce or prevent them. Of the 179 out of 240 (75%) who responded, 70 (39%) knew of at least one drug error in their unit during the last year, with 28 of them (40%) experiencing more than one. Of the most recent errors, giving the wrong drug (most commonly thiopental instead of antibiotics or vice versa [14 cases], or suxamethonium instead of [Formula: see text] [8 cases] or other drugs [4 cases]) was the most common error, occurring in 27 units (15%). Errors involving epidural/spinal analgesia/anaesthesia (including drugs intended for these routes but given via other routes) occurred in 20 cases. Only 36 respondents (20%) described protocols for checking anaesthetic drugs. Methods described for reducing drug errors were use of coloured labels (20%) or pre-filled labelled syringes (6%), limiting the range of drugs available (6%) and keeping drugs in separate trays once drawn up (6%).

1000 anaesthetic incidents: experience to date

The anaesthetic incident reporting scheme in Leicester has been running for 11 years and 1000 incidents have now been reported. The scheme has successfully highlighted weaknesses where a procedural change has been able to prevent repetition. It has provided advance notification of problems which could be overcome by publicity and has been a source of educational cases. The experience of this scheme supports the use of a definition which does not include blame and allows the possibility of anonymous reporting. The scheme has evolved, driven by hospital decisions on reporting risk management cases, by inclusion of the Royal College of Anaesthetists' incident categories and by progressive refinements. Summary figures are given for the different categories of incident. These show marked similarities with previous studies.

Avoiding inadvertent epidural injection of drugs intended for non-epidural use

Inadvertent administration of non-epidural medications into the epidural space has the potential for serious morbidity and mortality. The aim of this study was to collate reported incidents of this type, describe the potential mechanisms of occurrence and identify possible solutions. We searched medical databases and reviewed reference lists of papers retrieved, covering a period of 35 years, regarding this type of medication incident. The 31 reports of 37 cases found is likely to represent a gross underestimation of the actual number of incidents that occur. "Syringe swap", "ampoule error", and epidural/intravenous line confusion were the main sources of error in 36/37 cases (97%). Given that no effective treatment for such errors has been identified, prevention should be the main defence strategy. Despite all the precautions that are currently undertaken, accidents will inevitably occur. We have identified areas for systemwide change that may prevent these types of incidents from occurring in future.

Standardized colour coding for syringe drug labels: a national survey

A standardised colour code for user-applied syringe labels for anaesthetic drugs exists in the USA, Australia, New Zealand and Canada. In the UK, there is none. Consequently, an assortment of colour codes for syringe labels is available in the UK. We conducted a postal survey of the 285 College Tutors of the Royal College of Anaesthetists to establish their local syringe drug labelling system and their views on a national, standardised colour code. We found that that 96% of departments currently use coloured syringe drug labels. Of these, 98% use the 'Medilabel' scheme. The College Tutors felt that a standardised colour code for labels is required (94%), that the Association of Anaesthetists or the Royal College of Anaesthetists should be involved in the choice of scheme (76%) and that the scheme chosen should be international (65%). There was a majority feeling that the opinions expressed were representative of other members of the College Tutors' departments. We conclude that a national standard for drug labels is required and that a choice will have to be made between the 'international' scheme and the currently dominant Medilabel scheme.

A practical guide to the implementation of an effective incident reporting scheme to reduce medication error on the hospital ward

This paper discusses an anonymous incident reporting scheme to reduce drug administration error on the hospital ward, as part of an effective, non-punitive, systems-focused approach to safety. Drug error is costly in terms of increased hospital stay, resources consumed, patient harm, lives lost and careers ruined. Safety initiatives that focus, not on blaming individuals, but on improving the wider system in which personnel work have been adopted in a number of branches of health care. However, in nursing, blame remains the predominant approach for dealing with error, and the ward has seen little application of the systems approach to safety. Safety interventions founded on an effective incident scheme typically pay for themselves in terms of dollar savings arising from averted harm. Recent calls for greater health-care safety require finding new ways to make drug administration safer throughout the hospital, and the scope for such safety gains on the hospital ward remains considerable.

Safer epidural and spinal connectors

Inadvertent cross-connection of epidural local anaesthetic delivery systems with intravenous lines can cause significant morbidity and even death. Inadvertent intrathecal injection of toxic intravenous drugs has already led to many deaths. If epidural and spinal systems had the standard Luer lock connection reversed the problem would be prevented. The practical implications of this idea are explored. Patient safety would be enhanced if this system were adopted.

Evaluation in an anaesthetic simulator of a prototype of a new drug administration system designed to reduce error

Ten anaesthetists were observed while providing anaesthesia for two simulated surgical procedures, twice using conventional methods and twice using a prototype of a new drug administration system designed to reduce error. Aspects of each method were rated by users on 10-cm visual analogue scales (10 being best) and comments were invited. Median safety scores were 7.7 cm (range 4.3-8.9) for the new system and 4.6 cm (1.3-8.2) for conventional methods (p = 0.009). The new system was compared favourably with conventional methods in respect of safety (p = 0.005), clinical acceptability (p = 0.008), organisation and layout (p = 0.047), and acceptability for use on patients (p = 0.005). The new system saved time in the preparation of drugs both before anaesthesia (105 vs. 346 s; p < 0.001) and during anaesthesia (20 vs. 104 s; p < 0.001). Comments facilitated development of the system and the evaluation endorsed proceeding to a clinical trial.