The frequency and nature of drug administration error during anaesthesia in a Chinese hospital

Abstract

Our results are comparable with other international prospective estimates indicating that drug administration error is of concern in China as elsewhere. These results will form a baseline from which to detect the effects of countermeasures.

Review article: Improving drug safety for patients undergoing anesthesia and surgery

“…6 The focus of this current review is on strategies that are currently being engineered into care delivery systems to reduce drug-related errors in anesthetic practice. Such errors, which occur at a rate of about 1 per 130-450 patients, [7][8][9][10][11] are associated with increases in morbidity, mortality, and the costs of hospital care. [8][9][10][11][12] Fortunately, most anesthetic-related errors are inconsequential; however, some lead to substantial or permanent injury and even death.…”

“…Such errors, which occur at a rate of about 1 per 130-450 patients, [7][8][9][10][11] are associated with increases in morbidity, mortality, and the costs of hospital care. [8][9][10][11][12] Fortunately, most anesthetic-related errors are inconsequential; however, some lead to substantial or permanent injury and even death. 8,13 In this review, we focus on systems designed to reduce medication errors in the operating room and highlight three Canadian initiatives: 1) systematic efforts to improve the labelling of drug ampoules and vials, 2) introduction of bar-coding in medication systems, and 3) novel tools for ''reconciliation'' or for accurate documentation and adjustment of patients' medication taken before and during their hospital stay.…”

“…Based on a limited number of prospective studies, the estimated incidence of medication error in anesthetic practice ranges from 0.33-0.73%, 7,9 and the rate has not changed substantially in over 15 years. 11 Despite a growing awareness of the importance of drug safety, medication error is a major cause of medical malpractice for anesthesiologists in Canada.…”

In Reply

“…2,3 Thus, it is not surprising that these ME and ADE rates are higher than those described in previous studies using self-report as the primary detection strategy in anesthesia. 4–8 Our reported rates are consistent, and in many cases on the low end or lower than those reported using direct observation and similar ME definitions in the perioperative setting (ME rates 9–11%), 9 and those using our validated and widely used definition of ME with either chart review or direct observational methods in other settings such as the medical emergency/code setting (ME rates 4.4–50%), 10,11 critical care setting (ME rates 9–20%), 12,13 inpatient setting (ME rates 5–19%), 14–17 outpatient setting (ME rates 7–12%) 18–20 and simulation setting (ME rates 0.5–26.5%). 16,21 …”

“…4,8 We do not feel that these are valid comparisons for several reasons. First, evidence shows that incident reporting vastly underrepresents true error rates.…”