Audit of medication errors by anesthetists in North Western Nigeria

Abstract

Medication errors do occur in the everyday practice of anesthetists in Nigeria as in other countries and can lead to morbidity and mortality in our patients. Routine audit and reporting of critical incidents including errors in drug administration should be encouraged. Reduction of medication errors is an important aspect of patient safety, and vigilance remains the watchword.

Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate

“…In lowresource countries the actual number of medication errors is vastly understated and remains a key problem. 2,3 Failure to report medication errors in lowresource environments can occur for a variety of reasons International Journal of Obstetric Anesthesia including poor documentation, inattentiveness, inadequate staff or equipment, reliance on paper charting which can be lost, and poor handwriting. [1][2][3] Difficulties encountered in reporting this case included poor documentation and lack of laboratory assessment.…”

“…2,3 Failure to report medication errors in lowresource environments can occur for a variety of reasons International Journal of Obstetric Anesthesia including poor documentation, inattentiveness, inadequate staff or equipment, reliance on paper charting which can be lost, and poor handwriting. [1][2][3] Difficulties encountered in reporting this case included poor documentation and lack of laboratory assessment. The North American authors were not physically present during this case; however, they are part of the supportive and consultative role that is maintained with staff in this hospital through Kybele, Inc. 4 The North American authors were notified of this occurrence and a joint review of the case was conducted.…”

“…[1][2][3] While the true frequency of anesthesia-related medication errors is unknown, these errors are an increasing global health problem. [1][2][3] We describe the accidental intrathecal tranexamic injection in a low-resource setting that resulted in seizures that were refractory to standard therapy. Subsequent management and use of magnesium sulfate is discussed along with the initiation of a new operating room protocol for drug administration in an attempt to minimize the risk of this complication.…”

Inadvertent Intrathecal Injection of Atracurium: A Case Report

“…These aspects of minimizing errors drug administration are necessary in order to maintain a high level of safety. Reduction in the incidence of medication errors is an important aspect of patient safety, and vigilance remains the watchword in the safe conduct of anesthesia [15].…”

Medication Administration Error in Anaesthetic Practice: AReview of the African Experience

“…[20,22,23] The onus lies on Pharmaceutical companies to ensure that medication use in anaesthetic practice especially those for intravenous administration comes in defined and easily differentiated vials of various shapes, cap colour and sizes so as to assist the practicing anaesthetics to easily differentiate vials even in the case of an emergency.…”