Crisis management during anaesthesia: problems associated with drug administration during anaesthesia

Paix, A D; Bullock, M. F. M.; Runciman, William B.; Williamson, John

doi:10.1136/qshc.2002.004119

Cited by 11 publications

(4 citation statements)

References 14 publications

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“…Operating room is potentially a high risk area for medication errors [13] because only anaesthetists are responsible for administering medications and bypassing the mechanism of double checking in the wards and ICU by nurses, pharmacist, physician and computer. But due to under reporting by anaesthetists the incidence reported in different studies and in present study as well is low.…”

Section: Discussionmentioning

confidence: 99%

Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning

Hamid¹,

Akhtar²,

Minai³

et al. 2013

OJAnes

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Incident reporting is a reliable quality assurance tool, frequently used in anaesthesia to identify errors. It was introduced in anaesthesia by Cooper in 1978 and since then several institutions have adopted this system to find adverse events and near misses. We think that the incident reporting would be more beneficial for prolonged and technically complex procedures like paediatric cardiac surgery. Methods: All paediatric CHD patients scheduled for cardiac surgery were included in this audit. Thoracic and general surgery patients were excluded. Any event in preoperative area, induction room, operating room and during transfer to cardiac ICU was documented in a predesigned proforma by resident/consultant. This proforma included information regarding demographics, the type and severity and responsible factors for the event. Results: 134 patients were included in this two and half years audit. 88 patients were male (65.7%) and 46 (34.3%) were female. The age of the patients ranged from one day to 15 years. Total 105 incidents were noticed in 61 patients. 46 incidents were declared as major events which were potentially serious while 59 events were of minor nature. Cuffed endotracheal tube was used in 73% patients. The majority of events occurred in the pre-bypass period. Most of the incidents were related to cardiovascular system (73%), followed by pharmacological incidents. Human factors (74%) were mainly responsible for the incidents. Conclusion: Incident reporting is a reliable and feasible method of improving quality care in developing countries. It helps in identifying areas which need improvement and helps in developing guidelines to improve safety.

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Section: Discussionmentioning

confidence: 99%

Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning

Hamid¹,

Akhtar²,

Minai³

et al. 2013

OJAnes

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“…Pediatric anesthesia practice, in particular, may create additional risks because of the increased need for dilution and manipulation of medications and weight-based dosing calculations without formal cognitive support (8)(9)(10). Although many of these errors may not directly translate to patient harm, some can lead to devastating consequences (11,12).…”

Section: Introductionmentioning

confidence: 99%

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Martin

Grigg

Verma

et al. 2017

Pediatric Anesthesia

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SummaryThe Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding children's hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two-provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

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“…During administration of anesthesia, multiple drugs are given from different classes via various routes in fast-paced and high intensity environments. (1) Given the nature of anesthesia, in which most anesthesiologists administer over 250,000 drugs during their career,(2) medication errors are of significant concern. Anesthesiologists are likely to make one or more errors or near errors over the span of their careers.…”

Section: Introductionmentioning

confidence: 99%

“…Medication errors refer to situations in which a drug is erroneously administered and can occur at any point throughout the anesthetic process. (1) While the many causes and types of medication errors within anesthesia have been investigated, there is considerable variation among studies, leading to uncertainty regarding its magnitude. (19) There are studies with different designs such as case report/series, databases reviews, and retrospective or prospective survey studies that investigated the occurrence and outcomes of medication errors in anesthesia.…”

Section: Introductionmentioning

confidence: 99%

Medication administration errors during general anesthesia – a systematic review of prospective studies

Murphy

Sivaratnam

Wong

et al. 2023

Preprint

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Introduction The incidence of medication error in anesthesia can be variable among different studies likely due to recall bias in retrospective studies. In prospective survey studies, questionnaires are sent to anesthesia care providers to facilitate self-reports of medication errors during a pre-planned follow-up period. This systematic review investigates all prospective survey studies of medication errors in adult patients undergoing general anesthesia. Our objective is to identify the incidence and characteristics of the common medication errors during general anesthesia. We also want to determine the contributing factors and outcomes of these errors. Methods We conducted database searches of Embase and Medline for medication errors in anesthesia between 1980 to 2019 and 2020 to 2021. Ten prospective survey studies detailing medication errors involving adult patients under general anesthesia were included. Data on response rate, incidence of errors, types of error and medications, patient outcomes, and contributing factors were collected. Results Ten studies were included of which six studies provided a response rate ranging from 53% to 97.5%. The incidence of medication errors ranged from 0.02% to 1.12% or 1 in every 90 to 5000 anesthetics. A total of 1,676 medication errors during general anesthesia were analyzed. The most reported error was the substitution error (31.6% [530/1676]), followed by incorrect dose (28.4% [476/1676]). The class of medication most associated with administration errors were muscle relaxants, opioids, and antibiotics. Most patient outcomes were of no harm. Inexperience of the anesthesiologist, nurse or student was the most reported contributing factor, followed by haste or pressure to proceed, and communication problems. Conclusion The incidence of medication errors during general anesthesia were as high as 1.12% and the most common errors were substitution error and incorrect dose. Inexperience, time pressure, and communication problems were contributing factors. This information can be used to inform safety practices in anesthesia.

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Crisis management during anaesthesia: problems associated with drug administration during anaesthesia

Cited by 11 publications

References 14 publications

Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning

Errors during Paediatric Cardiac Anaesthesia: Reporting and Learning

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia

Medication administration errors during general anesthesia – a systematic review of prospective studies

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