MEDICATION ERRORS- MORE COMMON THAN YOU THINK. IMPLICATIONS IN REGIONAL ANAESTHESIA
Dr. Uma Shirdhar Iyer
9 slide(s) – English – 2011-09-08
Background and aims: Among the various errors seen in anaesthesia, medication errors rank high on the list. Medication errors can result in either adverse patient outcomes and/or financial implications. We conducted a survey among public sector and private practice anesthesiologists in Singapore during a 1 month period to determine the incidence of medication errors and its types.
Methods: We sent out 350 forms to anaesthetists, trainees and specialists, in institutions and in private practice. We classified the types of medication errors, the outcomes, factors that lead to its occurrence and the subsequent action taken as a fall out the errors
Results: We received 176 responses to the 350 forms distributed. we found a total of 116 errorscommitted by 82 doctors (46.59%). The most common type of error was accidental injection of muscle relaxants instead of reversal with neostigmine. Ampoule identification was aided by many features, but labeling was overwhelmingly the most important identifying feature for syringes. None of the errors resulted in major adverse outcomes or death
Conclusions: One in two anesthesiologists in Singapore will have a medication error in a lifetime of practice. Since, regional anaesthesia is increasingly being adopted in recent times, there is scope for errors to occur during drug dilution and administration. Suggestions include improve drug labeling practices, text-sizing and color coding which may impact the frequency of drug errors.