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Year : 2009  |  Volume : 53  |  Issue : 5  |  Page : 539-542 Table of Contents     

Drug Errors in Anaesthesiology

Department of Anaesthesiology and Critical Care, Bhopal Memorial Hospital andResearch Centre, Bhopal-462038, India

Date of Web Publication3-Mar-2010

Correspondence Address:
Rajnish Kumar Jain
Department of Anaesthesiology and Critical Care, Bhopal Memorial Hospital andResearch Centre, Bhopal-462038
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Source of Support: None, Conflict of Interest: None

PMID: 20640103

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Medication errors are a leading cause of morbidity and mortality in hospitalized patients. The incidence of these drug errors during anaesthesia is not certain. They impose a considerable financial burden to health care systems apart from the patient losses. Common causes of these errors and their prevention is discussed.

Keywords: Drug errors, Anaesthesia, Medication Errors

How to cite this article:
Jain RK, Katiyar S. Drug Errors in Anaesthesiology. Indian J Anaesth 2009;53:539-42

How to cite this URL:
Jain RK, Katiyar S. Drug Errors in Anaesthesiology. Indian J Anaesth [serial online] 2009 [cited 2021 Mar 6];53:539-42. Available from: https://www.ijaweb.org/text.asp?2009/53/5/539/60331

   Introduction Top

Medication error is a leading cause of morbidity and mortality in hospitalised patients. The practice of anaesthesiology requires the administration of a wide variety of potent medications. These medications are often given in high acuity situations and in environment with poor visibility and multiple distractions. Medica­tions with widely differing actions such as muscle re­laxants, vasopressors and vasodilators are often used in the course of a single anaesthetic, at times simulta­neously. Due to high potency, variety and frequency of drugs administered to patients undergoing anaesthesia, the potential exists for errors with disastrous conse­quences.

The Joint Commission in USA has made reduc­tion of medical errors one of its National patient safety goals for the past several years. In 2006, the FDA mandated that manufacturers include a machine read­able bar code, radiofrequency identification (RFID), and computerised ordered entry (CPOE) systems have all come on the horizons as technological solutions, only to create different problems which may be almost as big as those they are intended to solve. [1]

It is painfully obvious; we are yet nowhere near a solution, even for so called "high alert medication". The administration of flush solution with aheparin concen­tration 1000 times that intended to seventeen Texas neonates in Corpus Christi on July 4 th last year is just one very recent example of how far we have to go [2] .

Drug errors represented 4% claims in the ASA Closed Claims Project Report (2003). For ease, drug errors maybe classified into the following categories (after) Xlebster etal) [3].

  1. Omission - Drug not given
  2. Repetition-Extra dose of an intended drug
  3. Substitution- Incorrect drug instead of the desired drug: a swap
  4. Insertion- Adrug that was not intended to be given at a particular time or at any time
  5. Incorrect dose-Wrong dose of an intended drug
  6. Incorrect route-Wrong route of an intended drug
  7. Others-Usually amore complex event, not fitting the above categories

As per reports of Closed Claims Project (2003), out of 205 claims for drug errors, there were onlytwo cases of "omission", four cases of"incorrect route", and no cases of "repetition'. There were 50 cases of "substi­tution" (24%), 35 cases of "insertion" (17%), 64 cases of "incorrect dose" (31%), and 50 cases of "others" (24%). Drug infusions were involved in 30 cases (15%). Most common drug involved in infusion was succinyl choline. Drug administration errors frequently resulted in serious problems. There were 50 deaths (24%) and 70 cases with major morbidity Awide variety of drugs were involved in errors [Figure 1]. Two drugs in particular were most commonly involved. Succinyl choline was involved in 35 cases (17%) and Epinephrine was involved in 17 cases (8%). [4]

Medical literature is replete with anecdotal reports of medication errors that raise disturbing questions. How often do such tragedies occur in India? Unfortunately we don't know the answers to these questions because no mechanism exists to track medication errors or to develop strategies to prevent their recurrence. Significant research has already been done to evaluate drug administration procedures and technology to improve safety of drug administration during anaesthesia. These techniques are summarised in [Table 1] [1],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

However, major cause of drug error is misidentification of drug ampoules or vials. Confusing, inaccurate or incomplete labels contributed to 21% of the actual or potential drug errors reported to the US Pharmacopoeia practitioners network over a one year period (1999). [14] The recognition and identification of an object depends on the shape, colour, brightness and contrast. As these elements become increasingly distinctive, identification of the object becomes faster and more accurate. [15],[16],[17] Therefore, although multiple factors contribute to medication errors, consistency and clarity of pharmaceuticals and syringe labelling in accordance with human factors are important elements in their prevention.

American Society of Anaesthesiologists supports the manufacture and use of pharmaceuticals with labels meeting the following standards which are consistent with those established by American Society for Testing and Material (ASTM) International. The main change to the drug label is the introduction of a critical information panel or field. The label presents the generic name of the drug, the total amount per total volume and the drug concentration in black text on a white background. In addition, the drugs proprietary name, manufacturer, lot number, date of manufacture and expiry date should also be included on the label. The text on the label should be designed to enhance the recognition of the drug name and concentration as recommended in the ASTM international standards. [18]

Maximum Contrast between the text and the background should be provided by high contrast colour combinations as specified in ASTM international Standard [Table 2], which also minimise the impact of colour blindness. [18]

Nine Classes of drugs commonly used in practice of anaesthesiology have a standard background colour established for user applied syringe labels by ASTM international standards. For these drugs the colour of the containers top, label border, and any other coloured area on the label, excluding the background as required for maximum contrast, should be the colour respond­ing to the drugs classification [Table 3]. [18] Essential in­formation including the drugs generic name, concen­tration and volume of the vial or ampoule should be bar coded at a location on the vial or ampoule which will not interfere with the labels legibility as specified in AS TM international Standard. [17]

There are risks associated with usingthese colour coded syringes unless certain actions are taken to pre­vent syringe mix-ups that could prove harmful to pa­tients. Colour coding for user applied labels was pro­moted for anaesthesia providers only in Operation The­atres. It was not designed for commercial product la­bels. Commercially packaged colour coded syringes also have different easilyrecognisable colours for vari­ous pharmacological classes of anaesthesia drugs. But a serious risk exists; them are often multiple drugs within a class, each with very different properties. These drugs are all available in the same colour and perhaps the same size syringes. [19] Unlike anaesthesia providers who typically use a single drug within each class, commer­cial systems used to the fullest extent will result in many different agents within a class that share the same coloured syringe, risking drug selection errors. For ex­ample, it is possible to have three drugs, morphine, fen­tanyl and Pentazocine - each with significant potency variations, all in blue syringes in the same physical area. Mix-ups among these drugs could cause serious harm.

Colour coding strategies have led to repeated mix­ups ever since FDA allowed ophthalmologists and eye medication manufacturers to use a colour code classi­fication system for classes of eye drop medications. This is problematic when staff otherthan ophthalmolo­gist dispense or administer these drugs. [19]

While injuries may not be serious when a mix-up occurs between various eye drops, mix-ups between powerful anaesthesia drugs, mostly all high alert medi­cations can prove fatal. Within the Operation Theatre (OT) most patients are intubated, monitored and have immediate care available in case of serious mix-ups. Outside the OT, mix-ups may be more difficult to recognise and manage quickly. To reduce the risk of these mix-ups commercial repackagers should label these products with warnings to encourage use by ana­esthesia providers within the OT only. Standards should be modified by including drug names along the borders and additional colours along the edges to help differen­tiate products within each class. Bar coding systems would likely prevent most mix-ups; there is a barcode on these commercially available syringes. [19]

The next step towards a safer drug delivery sys­tem is the establishment of an agency for reporting medication errors. This agency would be similar to the American institute of safe medical practice (ISMP). [14] The Med Marx programme ofthe US Pharmacopoeia (www.usp.org) enables health care professionals to report anonymous ly their concerns regarding the qual­ity, safety, performance or design of products used in their practice .This non profit organisation identifies causal mechanisms and develop strategies to prevent their recurrence. This information is then shared with industry and appropriate government Agencies.

An investigation by Fasting et al showed that drug errors are uncommon and represent a small part of anaesthesia problems but still have the potential for serious morbidity. [13] According to them syringe swaps occurred between syringes of equal sizes and were not eliminated by colour coding of labels. As per this study, system improvement by better visual cues and better checking procedures are needed. [13] Reading the label before giving the drug is still the last in the line of mul­tiple defences againstthe problem of drug error.

As evidenced by the latest JCAHO sentinenel events report (2009), anaesthesiology speciality con­tinues to grapple with suboptunal outcomes, mostly related to poor communication. [20] Anaesthesiaprovid­ers work hours and practice settings are more variable than in the past and attendant breakdowns in clinical information transfer can lead to systemic medical er­rors. Current evidence indicates that improving clinical communication can also reduce medical error to some extent.

Thus, drug errors are an inevitable consequence of the human condition, they occur even among the most conscientious medical professionals. During the pasttwo decades anaesthesiology has led many patient safety improvement initiatives and morbidity and mortality rates have decreased greatly as a result. [21]

   References Top

1.FDA Issues Bar Code Regulation. February 25, 2004: United States Food and Drug Administration. Avail­able at: http://www.fda.gov/oc/initiatives/bareode-sadr/fs-barcode.html.  Back to cited text no. 1      
2.Donald E.Martin.Medication error persists. APSF News­letter 2008. Available at http ://www. apsf. org/resource center/newsletter/2008/fall/OI errors.htm  Back to cited text no. 2      
3.Webster CS, MerryAF, LarssonL, McGrath KA, Weller J. The frequency and nature of drug administration er­ror during anaesthesia. Anaesth Intensive Care 2001; 29:494500.  Back to cited text no. 3      
4.Bowclle, TA. Drug Administration errors from the ASA closed claims project. ASANewsletter 2003;67:11-13.  Back to cited text no. 4      
5.Jensen L S, MerryAF, Webster CS, et al. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004;   Back to cited text no. 5      
6. 59: 493-504.  Back to cited text no. 6      
7.AbeysekeraA, Bergman IS, Kluger MT, et al. Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database. Ana­esthesia 2005; 60:220-7.  Back to cited text no. 7      
8.Orser BA, Oxom DC. An anaesthetic drug error: mini­mizing the risk. Can JAnaesth 1994; 41:120-4.  Back to cited text no. 8      
9.Currie M, Mackay P, Morgan C, et al. The "wrong drug" problem in anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21:596-601.  Back to cited text no. 9      
10.Kaushal R, BatesDW Information technology and medi­cation safety: what is the benefit? Qual Saf Health Care 2002;11:261-5.  Back to cited text no. 10      
11.Merry AF, Webster CS, Mathew DJ. Anew, safety-ori­ented, integrated drug administration and automated anaesthesia record system. AnesthAnalg 2001; 93:385­90.  Back to cited text no. 11      
12.Merry AF, Webster CS, Weller J, et al. Evaluation in an anaesthetic simulator of a prototype of a new drug administration system designed to reduce error. Anaes­thesia 2002; 57:256-63.  Back to cited text no. 12      
13.Kohn LT, Corrigan JIM, Donaldson MS. To err is human: building a safer health system. Committee on the Qual­ity of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press, 1999.  Back to cited text no. 13      
14.Fasting S, Grisvold S. Adverse drug errors in anaesthe­sia, and the impact of coloured syringe labels. Can J Anaesth 2000; 47:1060-7.  Back to cited text no. 14      
15.Orser B. Reducing Medication Errors. JAMC 2000;162:1150-1151.  Back to cited text no. 15      
16.TreismannA. Feature and objects in visual processing. ScientificAmerican 1986;255:114-125.  Back to cited text no. 16      
17.Treismann A. Features and objects-Quarterly J.of Exp.Psychology 1988; 40A:201-237.  Back to cited text no. 17      
18.Kossylyn SM. Aspects of a cognitive neuroscience of mental imagery. Science 1988; 240:1621-1626.  Back to cited text no. 18      
19.Statement on the labelling of pharmaceuticals for use in anaesthesiology: 2004. ASTM International Standards.  Back to cited text no. 19      
20.Colour coded Syringes for anaesthesia drugs: Use with care. 2009. IS v ..  Back to cited text no. 20      
21.William T.O'Byrne, Liza W, Selby J. The science and economics of improving clinical communication. Anes­thesiology Clinics 2008; 26:4:729-744.  Back to cited text no. 21      


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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