Preventing medication errors in anesthesia and critical care (abbreviated version)

Abstract

Drug medication errors remain a major safety issue in anaesthesia and intensive care, and prevention measures need to be strengthened. This is why the French Society of Anaesthesia and Intensive Care and the French Society of Clinical Pharmacy have profoundly reviewed their previous recommendations published in 2007. The 2017 recommendations are based on the literature but also on feedback from field professionals targeting patient safety. They share many similarities with recommendations issued from other countries (European countries, North America and Australia in particular) on this subject. Specific measures to prevent preparation, reconstitution and administration errors are detailed. Medical products using small bore connectors specified in the ISO 80369 series allow the prevention of administrtion errors. Specific labeling should be used according to an international color-coding of syringes, routes of administration, preparation bags, PCAs and PCEAs, trolleys or drug storage devices. A risk mapping must be established a priori and medication errors reporting is imperative in order to analyze them a posteriori in departmental meetings (REMED). Self-assessment, or external assessment, must be conducted. All of the proposed recommendations reinforce the culture of safety, which is essential to the practice of anaesthesia and intensive care.

Local anesthetic systemic toxicity: current perspectives

“…The transition from Luer connectors to new ISO 80369 standard small-bore connecters might also reduce the risk of wrong route injection. 77 , 78 …”

Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error

“…[20,21] All health facilities should ensure that they have clearly written policies that minimise medication errors, and then audit and appraise errors that do occur. [22] This approach should nurture a culture of drug safety, including multidisciplinary involvement, ongoing education and specific evidence-based interventions. [22] However, despite vociferous calls for changes in practice, merely exhorting doctors to be more careful is often inadequate.…”

“…[22] This approach should nurture a culture of drug safety, including multidisciplinary involvement, ongoing education and specific evidence-based interventions. [22] However, despite vociferous calls for changes in practice, merely exhorting doctors to be more careful is often inadequate. [23] Ideally, system changes should make it impossible for error to occur.…”

“…We have made recommendations in Table 2 summarising key interventions aimed at reducing drug error from the relevant literature. [12,[19][20][21][22]25] Importantly, this clinical alert applies equally to both the private and public sectors in SA, where different versions and appearances of the drug ampoules are available. Fig.…”

Choice of hypnotic drug for obstetric and non-obstetric general anaesthesia. Comment on Br J Anaesth 2020; 125: e81–7

“… 9 Reintroducing thiopental in the operating theatre could provide an opportunity to strengthen education and teaching focusing on drug preparation, labelling, and administration, contributing to improve practice and increase safety. 10 …”