Medication Errors in Anesthesia

Cooper, Lebron; Nossaman, Bobby D.

doi:10.1097/aia.0b013e31827d6486

Cited by 43 publications

(24 citation statements)

References 20 publications

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“…The most common causes of perioperative DAE include injection of the incorrect drug, administration of an excessive dose, incorrect route of administration and negligence. Inadequate follow-up of treatment or side effects, inadequate standardization of labels and protocols, carelessness, excessive workload, inappropriate working hours, poor communication, impetuousness, fatigue, medical and paramedical staff-related problems were also reported to contribute to DAE (4,8,14,(17)(18)(19)(20)(21)(22)(23)(24). In addition, incorrect or missing drug labels, interchange of syringe labels and vials, unlabeled syringes, and failure to estimate the dose of the drug were also reported (5,7,8,12,22).…”

Section: Discussionmentioning

confidence: 99%

Attitudes and Behaviors of Anesthesia Workers in Turkey Towards Drug Labeling: A Questionnaire Study

Küçükosman¹,

Aydın²,

Ayoğlu³

2019

Istanbul Med J

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Amaç: Standart ilaç enjektör etiketleri ilaç hatalarını azaltabilir. Çalışmamızda, ülkemizde anestezi çalışanının (AÇ) ilaç etiketleme konusundaki tutumlarını, ilaç hatalarında etiketlemenin önemini vurgulamak ve standardizasyon bilincinin artmasına yönelik bir farkındalık yaratarak güvenli anestezi uygulamalarına katkı sağlanması amaçlanmıştır. Yöntemler: Bu çalışma Zonguldak Bülent Ecevit Üniversitesi Klinik Araştırma Etik Kurulu'ndan izin alındıktan sonra tamamlandı. Türk Anesteziyoloji ve Reanimasyon Derneği'nin her üyesine ve posta adresleri bilinen teknisyenlere gizli, kendi kendini raporlama anketi gönderildi. Bulgular: Toplam 189 kişi katıldı. Katılımcıların %49,2'si standart enjektör etiketinin (SEE) farkındaydı. Bu katılımcıların %67,3'ü renk kodlu kendinden yapışkanlı etiket kullandıklarını belirtirken, %47'si bu etiketlerin hangi standartları karşıladığını bilmediklerini belirtmiştir. AÇ'ler ilaç uygulama hatalarını (İUH) azaltmak için; renk kodlu kendinden yapışkanlı etiketlerin %92,9, flakonların %97,3 ve önceden hazırlanmış SSE'nin %87,8 oranında etkili olacağını belirtti. Katılımcıların %89,9'u İUH bildirmediğini, %84,7'si, uygulama öncesi her defasında etiketi okuduğunu belirtti. AÇ'ler, İUH'yi önlemede SEE'nin (%47), dikkat (%23), eğitim (%21) ve flakon-ampullerin farklı renk ve boyutlarda yapılması (%9) gerektiğini belirtmişlerdir. Sonuç: AÇ'ler, etiketleme ile ilgili hataların önlenmesi için; flakon etiketlerinin geliştirilmesinin ve standartlaştırılmasının, eğitimlerin planlanmasının, özen ve dikkatin önemini belirtmiştir.

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Section: Discussionmentioning

confidence: 99%

Attitudes and Behaviors of Anesthesia Workers in Turkey Towards Drug Labeling: A Questionnaire Study

Küçükosman¹,

Aydın²,

Ayoğlu³

2019

Istanbul Med J

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“…That gave us a combined incidence of 1 in 211 medication errors in anesthesia practice. [12] Based on a limited number of prospective studies, the incidence of medication error in anesthetic practice ranges from 0.33% to 0.73%, and shockingly, this rate has not changed over the last 15 years. [8]…”

Section: Incidencementioning

confidence: 99%

Root cause analysis of blunders in anesthesia

2019

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The frequency of blunders perioperative because of anesthesia is expanding, and the precise occurrence is significantly thought little of practically due to underreporting. Root cause analysis of majority of anesthesia errors due to lack of knowledge, unfollow the patient procedures and guidelines, medications errors and lack of communication between the members of anesthesia team leading to morbidity or even mortality. The cornerstone in the operating room environment is the communication, especially the patient's data are accumulated and changed continuously during a patient's anesthesia. Continuous attempts for establishing Iideal strategies to reduce the incidence and chance of anesthesia errors. The advancement of a nonaccuse condition where mistakes are transparently revealed and talked about, and guidelines for naming the medication holders, vials, and ampoules are focused. All endeavors ought to be made in the revealing and anticipation of medical drug errors. It is time to incorporate electronic and digital concepts to encourage the evolution of anesthesia-related drug delivery system.

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“…For example, whether ‘near misses’ also count, such as attaching the wrong syringe to an intravenous (i.v.) line but not actually administering the drug , or whether written prescription errors that are not translated into practice are relevant . The majority of drug errors clearly lead to little or no harm, but are very important to measure as indicators from which to learn to improve practice overall.…”

Section: Introductionmentioning

confidence: 99%

Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue

Sivia¹,

Pandit

2019

Anaesthesia

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The incidence of an anaesthetic drug error can be directly observed in large trials. In an alternative approach, we developed a probabilistic mathematical model in which the anaesthetist is modelled as a 'fallible entity' who makes repeated drug administration choices during an operation. This fallibility was factored in the model as an initial 'intrinsic error rate'. The choices faced included: dose; timing of administration; and the routes available for injection (e.g. venous, arterial, epidural, etc.). Additionally, we modelled the effect of fatigue as a factor that magnifies the cumulative error rate. For an initial intrinsic error rate of 1 in 1000 (which from first principles we consider a reasonable estimate), our model predicted a cumulative probability of error over a~12 h operation of~10%; that is, 1 in 10 operations this long results in some drug error. This is similar to the rate reported by large observational trials. Serious errors constitute a small fraction of all errors; our model predicts a Poisson distribution for the uncommon serious errors, also consistent with independent observations. Even modest assumptions for the development of fatigue had a dramatic and adverse impact on the cumulative error rate. The practice implications of our modelling include: exercising caution or avoiding starting work if under par; added vigilance in unfamiliar environments; keeping anaesthetic recipes simple; and recognising that operation durations > 5-6 h constitute a time of exaggerated risk. These implications are testable predictions in observational trials. If validated, our model could serve as a potential research tool to investigate the impact of safety interventions on the rate of intrinsic error using simulation.

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Medication Errors in Anesthesia

Cited by 43 publications

References 20 publications

Attitudes and Behaviors of Anesthesia Workers in Turkey Towards Drug Labeling: A Questionnaire Study

Attitudes and Behaviors of Anesthesia Workers in Turkey Towards Drug Labeling: A Questionnaire Study

Root cause analysis of blunders in anesthesia

Mathematical model of the risk of drug error during anaesthesia: the influence of drug choices, injection routes, operation duration and fatigue

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