Medication Errors in Anaesthesia: Let’s tackle the challenge

Medication Errors in Anaesthesia: Let’s tackle the challenge

  • issue 77

Daniel Arnal-Velasco
daniel.arnal@esahq.org

Think about it. How many times have you witnessed, been involved, or heard about a medication error in your department? How many times did somebody take the wrong syringe? How many times have you heard about an inadequate dosage after inadequate verbal communication, such as ‘give two ml’? What about an untended bolus of vasopressors or opioids, or an epidural administration of an intravenous prescribed medication? Just some examples of a long list. Medication errors are around us, let’s face it.

We should not be surprised, though. Medication administration is our main therapeutic tool as anaesthesiologists. It is what we do every day in an environment that ranges from a routine, quiet, ASA-I in a routine hernia surgery to a highly complex, unpredictive, ASA-IV emergent cardiothoracic surgery, a busy ICU environment, or the critical box in the emergency department.

Taking a wider perspective, and following their well-known previous Global Patient Safety Challenges, Clean Care is Safer Careand Safe Surgery Saves Lives, the World Health Organization (WHO) initiated its third campaign, Medication Without Harm,1 by acknowledging that unsafe medication practices and errors are a leading cause of avoidable harm across the world, with an estimated cost of US$ 42 billion annually. WHO asks countries and key stakeholders to prioritize three key areas:

  • High risk situations
  • Polypharmacy
  • Transitions of care

No matter how you look at it, anaesthesiology and critical care sign for these three areas. Even more, we are unique among all healthcare drug prescribers in having the responsibility to prescribe, prepare, and administer high risk medications without an independent verification.

The real prevalence of medications errors in the perioperative setting is a matter of discussion as all the strategies to study them have their downsides.2 Although retrospective studies may provide large denominators, they tend to underestimate adverse events. Prospective incident monitoring studies have reported drug administration error in a range from 0.37% 3 to 0.75% 4 per anaesthetic case. The rate seems to be higher in paediatric cases, with at least one medication error in 2.6% of the cases.5 Prospective direct observational studies identify even higher error rates than self-reporting, ranging from 0.32% of drug administration or 3.2% of anaesthetics 6 to one in twenty drug administrations and one every second case.7 Does it sound high? Well, it depends on where we set the medication error definition threshold.2

Even taking the most conservative numbers and performing a mental calculation of the anaesthetics and medications that we are to administer in the following months, we know that we – you and I – will omit, mistake, overdose, or fail to monitor a high number of drugs to our patients.

The challenge to deliver medication without harm is unavoidable. Conferences8 and recommendations 9, 10 try to offer a framework for improvement. European Board of Anaesthesiology (EBA) recommendations10 focus on drug syringe preparation and correct labelling, drug packaging, drug contamination and transmission of infections, distractions, supply problems, and incident reporting, providing a final easy-to-follow checklist to help departments implement the guidelines.

The use of pre-printed labels following the International Organisation for Standardisation (ISO) colours and design11 is a cheap strategy to reduce medication confusion between different medication groups, but still lacks the reduction of the error-prone complexity of IV medication preparation and administration. Ready-to-administer medications, either commercial compounds or pre-filled syringes, when available, have the potential to simplify the process and, hence, improving patient safety.12

The anaesthesia workspace is also susceptible to better standardization: Infrequently used, emergency medications should be stored in a distinctive location; medications that look alike ought to be separated; and standard layout helps providers to create a mental model that makes mistakes less likely.13 The Anaesthesia Medication Template14 or the Rainbow Tray15 are examples of applying design principles to anaesthesia.

Team-Based practice, such as Independent Double Checksfor selected dangerous medications, is another recommended practice16 to reduce medication errors related to distractions, although workload and staff shortage limit its wider application. Automated double checks such as barcode scanning may yield even better results, but it is difficult to implement in the anaesthesia setting where the drugs are administered without prescription, pharmacy is not involved, and medications are drawn from individual vials in a drawer.13

The future may include a bundle of actions that would include highly standardized workspace with barcoded pre-filled syringes that would be scanned through intelligent ports or other available equipment in connection with the electronic record and monitoring, simplifying the administration and recording process, running an automated universal double check and providing algorithm-based cognitive aids and decision-making aids to manage or even advance the drug effects.

Until we build that future, we still have plenty of work to acknowledge the relevance of medication errors, learn from them, and implement the safety culture and standardization processes to avoid their repetition or minimize their impact. For more of this discussion, join us at the Detecting and eliminating medication errorssymposium at Euroanaesthesia 2019, Vienna.

 

References

[1]. Medication Without Harm – Global Patient Safety Challenge on Medication Safety. Geneva: World Health Organization, 2017. Licence: CC BY-NC-SA 3.0 IGO.

[2]. Webster CS. Eur J Anaesthesiol2018;35(1):60-1.

[3]. Llewellyn RL, Gordon PC, Wheatcroft D, et al. Anaesth Intensive Care2009;37(1):93-8.

[4]. Webster CS, Merry AF, Larsson L, et al. Anaesth Intensive Care2001;29(5):494-500.

[5]. Gariel C, Cogniat B, Desgranges FP, et al. Br J Anaesth2018;120(3):563-70.

[6].Merry AF, Webster CS, Hannam J, et al. BMJ2011;22:343.

[7]. Nanji KC, Patel A, Shaikh S, et al. Anesthesiology2016;124(1):25-34.

[8]. APSF Stoelting Conference 2018. https://www.apsf.org/event/apsf-stoelting-conference-2018/

[9]. Institute for Safe Medication Practices (ISMP). ISMP Safe Practice Guidelines for Adult IV Push Medications; 2015. https://www.ismp.org/guidelines/iv-push

[10]. Whitaker D, Brattebø G, Trenkler S, et al. Eur J Anaesthesiol2017;34(1):4-7.

[11]. User-applied labels for syringes containing drugs used during anaesthesia – Colours, design and performance.1st ed. Geneva: ISO, 2008.

[12]. Yang Y, Rivera AJ, Fortier CR, et al. Anesthesiology2016;124(4):795-803.

[13]. Grigg EB, Roesler A. Anesth Analg2018;126(1):346-50.

[14]. Grigg EB, Martin LD, Ross FJ, et al. Anesth Analg2017;124(5):1617-25.

[15]. Almghairbi DS, Sharp L, Griffiths R, et al. Anaesthesia2018;73(3):356-64.

[16].ISMP. https://www.ismp.org/resources/independent-double-checks-undervalued-and-misused-selective-use-strategy-can-play