Drug Safety in Anaesthesia

Medication error is a major cause of morbidity in anaesthetic practice.

Definitions

Key terms:

  • Error
    Failure of intended plan to be completed, or the use of a wrong plan to achieve a goal. May be of:
    • Commission
    • Omission
  • Medication error
    An error in the medication process; irrespective of consequences.
  • Adverse drug reaction
    Injury related to use of a drug. Independent of error.
  • Preventable
    Harm that could have been avoided through reasonable planning or correct execution of a plan.
  • Near miss
    Error that does not result in harm.
  • Slip
    Failure to execute an action due to misdirection of routine behaviour.
  • Lapse
    Failure to execute an action due to lapse in memory causing omission of a routine behaviour.

Risk Factors

Anaesthetic-related drug errors are associated with:

  • Self
    • General inexperience
    • Unfamiliarity with drug
    • Unfamiliarity with environment
    • Haste
    • Inattention
      • Fatigue
      • Hungry
      • Angry
      • Late
      • Tired
    • Mathematics
      • Dilutions
  • Environment
    • Overnight
    • Poor communication
    • Restricted visual field
    • Poor labeling
      Including:
      • Ampoule
      • Syringes
      • Unlabeled syringes
    • Situational chaos
  • Patient
    • Emergency case

Minimisation

Focuses on:

  • Self
    • Maintain vigilance
      • Adequate breaks
      • Self-discipline
    • Process rules:
      • Only handle one medicine at a time
      • Quarantine preparation
        Avoid distraction during preparation.
      • Check every vial before and after drawing up
      • Label all syringes and IV bags
      • Use a standard order and syringe tray
      • Do not draw up medications until required
      • Do not draw up reversal and relaxant at the same time
        They are never needed together.
      • Always use a red syringe for NMBA
      • Draw up the whole ampoule of NMBA into the syringe
      • Do not use red syringes for reversal
      • Have a separate section for storing:
        • Medicines given in an emergency
        • Medicines given by a route other than IV
          e.g. Local anaesthetics.
        • Medicines that would be harmful outside of the specific purpose
          e.g. Oxytocin, protamine.
  • Environment
    • Reduce complexity
    • Organised drug trolleys
      Unique within one area of department.
    • Use of pre-filled syringes
  • Team
    • Double-checking of ampoules
    • Audit of errors

References

  1. Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia. 2019;74(3):280-284. doi:10.1111/anae.14482
  2. Glavin RJ. Drug errors: consequences, mechanisms, and avoidance. Br J Anaesth. 2010;105(1):76-82. doi:10.1093/bja/aeq131