Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2014.06.011
Brazilian Journal of Anesthesiology
Miscellaneous

Profile of drug administration errors in anesthesia among anesthesiologists from Santa Catarina

Perfil de erros de administração de medicamentos em anestesia entre anestesiologistas catarinenses

Thomas Rolf Erdmann; Jorge Hamilton Soares Garcia; Marcos Lázaro Loureiro; Marcelo Petruccelli Monteiro; Guilherme Muriano Brunharo

Downloads: 0
Views: 629

Abstract

INTRODUCTION: 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. OBJECTIVE: Access the prevalence of drug administration errors during anesthesia among anesthesiologists from Santa Catarina, the circumstances in which they occurred, and possible associated factors. MATERIALS AND METHODS: 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. RESULTS: 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%). CONCLUSION: Most respondents committed more than one error in anesthesia administration, mainly justified as a distraction or fatigue, and of low gravity.

Keywords

Medical errors, Drug errors, Anesthesiology, Anesthesia

Resumo

INTRODUÇÃO: A anestesiologia é a única especialidade médica que prescreve, dilui e administra os fármacos sem conferência de outro profissional. Somando-se a alta frequência de administração de fármacos, cria-se o cenário propício aos erros. OBJETIVO: Verificar a prevalência dos erros de administração de medicamentos durante anestesia, entre anestesiologistas catarinenses, as circunstâncias em que ocorreram e possíveis fatores associados. MATERIAIS E MÉTODOS: Um questionário eletrônico foi enviado a todos os anestesiologistas da Sociedade de Anestesiologia do Estado de Santa Catarina contendo respostas diretas ou de múltipla escolha sobre dados demográficos e perfil da prática anestésica do entrevistado; prevalência de erros, tipo e consequência do erro; e fatores que possivelmente contribuíram para os erros. RESULTADOS: Dos entrevistados, 91,8% afirmaram ter cometido erro de administração, somando total de erros de 274 e média de 4,7 (6,9) erros por entrevistado. O erro mais comum foi substituição (68,4%), seguido por erro de dose (49,1%) e omissão (35%). Apenas 7% dos entrevistados referiram erros de administração no neuroeixo. Quanto às circunstâncias dos erros, ocorreram principalmente no período matutino (32,7%), na manutenção da anestesia (49%), com 47,8% sem danos ao paciente e 1,75% com maior morbidade com dano irreversível e em 87,3% dos casos a identificação imediata. Quanto aos possíveis fatores contribuintes, os mais frequentes foram: distração e fadiga (64,9%) e leitura errada dos rótulos de ampolas ou seringas (54,4%). CONCLUSÃO: A maioria dos anestesiologistas entrevistados cometeu mais de um erro de administração em anestesia, principalmente justificado como distração ou fadiga, de baixa gravidade.

Palavras-chave

Erros médicos, Erros de medicação, Anestesiologia, Anestesia

References

Leape LL, Brennan TA, Laird N. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med.. 1991;324:377-84.

Glavin RJ. Drug errors: consequences, mechanisms, and avoid- ance. Br J Anaesth.. 2010;105:76-82.

Phillips DP, Christenfeld N, Glynn LM. Increase in US medica- tion error deaths between 1983 and 1993. Lancet.. 1998;351:643-4.

Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology.. 1984;60:34-42.

Hove LD, Steinmetz J, Christoffersen JK. Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Asso- ciation. Anesthesiology.. 2007;106:675-80.

Webster CS, Merry AF, Larsson L. The frequency and nature of drug administration error during anaesthesia. Anaesth Inten- sive Care.. 2001;29:494-500.

Khan FA, Hoda MQ. Drug related critical incidents. Anaesthesia.. 2005;60:48-52.

Llewellyn RL, Gordon PC, Wheatcroft D. Drug admin- istration errors: a prospective study survey from three South African teaching hospitals. Anaesth Intensive Care.. 2009;37:93-8.

Zhang Y, Dong YJ, Webster CS. The frequency and nature of drug administration error during anaesthesia in a Chinese hospital. Acta Anaesthesiol Scand.. 2013;57:158-64.

Cooper L, Nossaman B. Medication errors in anesthesia: a review. Int Anesthesiol Clin.. 2013;51:1-12.

Orser BA, Chen RJ, Yee DA. Medication errors in anes- thetic practice: a survey of 687 practitioners. Can J Anaesth.. 2001;48:139-46.

Currie M, Mackay P, Morgan C. The Australian Incident Monitoring Study. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care.. 1993;21:596-601.

Abeysekera A, Bergman IJ, Kluger MT. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Anaesthesia.. 2005;60:220-7.

Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anaesth.. 2000;47:1060-7.

Reason JT. Human error: models and management. Br Med J.. 2000;320:768-70.

Wheeler SJ, Wheeler DW. Medication errors in anaesthesia and critical care. Anaesthesia.. 2005;60:257-73.

Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. J Am Med Assoc.. 2002;288:501-7.

5dcd9ca70e88254662bf58f2 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections