Medication Errors in Anesthesia

*Department of Anesthesiology, University of Miami Miller School of Medicine Miami, Florida †Ochsner Clinic Foundation. Ochsner Health System New Orleans, Louisiana.
International anesthesiology clinics 01/2013; 51(1):1-12. DOI: 10.1097/AIA.0b013e31827d6486
Source: PubMed
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    ABSTRACT: Anesthesiology is the only medical specialty that prescribes, dilutes, and administers drugs without conferral by another professional. Adding to the high frequency of drug administration, a propitious scenario to errors is created. Access the prevalence of drug administration errors during anesthesia among anesthesiologists from Santa Catarina, the circumstances in which they occurred, and possible associated factors. An electronic questionnaire was sent to all anesthesiologists from Sociedade de Anestesiologia do Estado de Santa Catarina, with direct or multiple choice questions on responder demographics and anesthesia practice profile; prevalence of errors, type and consequence of error; and factors that may have contributed to the errors. Of the respondents, 91.8% reported they had committed administration errors, adding the total error of 274 and mean of 4.7 (6.9) errors per respondent. The most common error was replacement (68.4%), followed by dose error (49.1%), and omission (35%). Only 7% of respondents reported neuraxial administration error. Regarding circumstances of errors, they mainly occurred in the morning (32.7%), in anesthesia maintenance (49%), with 47.8% without harm to the patient and 1.75% with the highest morbidity and irreversible damage, and 87.3% of cases with immediate identification. As for possible contributing factors, the most frequent were: distraction and fatigue (64.9%) and misreading of labels, ampoules, or syringes (54.4%). Most respondents committed more than one error in anesthesia administration, mainly justified as a distraction or fatigue, and of low gravity. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
    Revista brasileira de anestesiologia 12/2014; DOI:10.1016/j.bjan.2014.06.004 · 0.51 Impact Factor