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: The incidence of medications errors is increasing and the exact incidence is likely greatly underestimated and under-reported. Although the majority of these errors occur due to lack of knowledge of or failure to follow accepted protocols, look alike medication containers are the primary cause in many cases of drug error related morbidity or even mortality. With the number of drugs and the number of pharmaceutical companies manufacturing the same drug on an increase, the incidence is likely to increase. It is a universal problem that can be found in any operating room throughout the world, as demonstrated by the multi-national representation of many reports on this subject in the literature. This editorial supplements a case report, the ‘Clinipics®’ page and a special article on the topic of hazards of look-alike drug containers published in this issue of Anaesthsia, Pain & Intensive Care. The authors also attempt to present strategies to reduce these medication errors. The development of a non-blame environment where errors are openly reported and discussed and regulations for labeling the drug containers, vials and ampoules is stressed. Key words: Medication errors; Medication Errors/prevention & control; Morbidity; Mortality; Drug containers; Root cause analysis Citation: Tobias JD, Yadav G, Gupta SK, Jain G. Medication errors: A matter of serious concern. Anaesth Pain & Intensive Care 2013;17(2):111-114
    Anaesthesia, Pain and Intensive Care 09/2013; 17(2):111-114.
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    ABSTRACT: The Codonics Safe Labeling System(™) ( is a piece of equipment that is able to barcode scan medications, read aloud the medication and the concentration and print a label of the appropriate concentration in the appropriate colour code. We decided to test this system in our facility to identify risks, benefits and usability. Our project comprised a baseline survey (25 anaesthesia cases during which 212 syringes were prepared from 223 drugs), an observational study (47 cases with 330 syringes prepared) and a user acceptability survey. The baseline compliance with all labelling requirements was 58%. In the observational study the compliance using the Codonics system was 98.6% versus 63.8% with conventional labelling. In the user acceptability survey the majority agreed the Codonics machine was easy to use, more legible and adhered with better security than the conventional preprinted label. However, most were neutral when asked about the likelihood of flexibility and customisation and were dissatisfied with the increased workload. Our findings suggest that the Codonics labelling machine is user-friendly and it improved syringe labelling compliance in our study. However, staff need to be willing to follow proper labelling workflow rather than batch label during preparation. Future syringe labelling equipment developers need to concentrate on user interface issues to reduce human factor and workflow problems. Support logistics are also an important consideration prior to implementation of any new labelling system.
    Anaesthesia and intensive care 07/2014; 42(4):500-506. · 1.30 Impact Factor
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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
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