Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system.

BACKGROUND: Anaesthetic medication administration errors are a significant threat to patient safety. In 2002, we began collecting data about the rate and nature of anaesthetic medication errors and implemented a variety of measures to reduce errors. METHODS: Facilitated self-reporting of errors was carried out in 2002-2003. Subsequently, a medication safety bundle including 'smart' infusion pumps were implemented. During 2014 facilitated self-reporting commenced again. A barcode-based medication safety system was then implemented and the facilitated self-reporting was continued through 2015. RESULTS: During 2002-2003, a total of 11 709 paper forms were returned. There were 73 reports of errors (0.62% of anaesthetics) and 27 reports of intercepted errors (0.23%). During 2014, 14 572 computerised forms were completed. There were 57 reports of errors (0.39%) and 11 reports of intercepted errors (0.075%). Errors associated with medication infusions were reduced in comparison with those recorded in 2002-2003 (P<0.001). The rate of syringe swap error was also reduced (P=0.001). The reduction in error rate between 2002-2003 and 2014 was statistically significant (P=0.0076 and P=0.001 for errors and intercepted errors, respectively). From December 2014 through December 2015, 24 264 computerised forms were completed after implementation of a barcode-based medication safety system. There were 56 reports of errors (0.23%) and six reports of intercepted errors (0.025%). Vial swap errors in 2014-2015 were significantly reduced compared with those in 2014 (P=0.004). The reduction in error rate after implementation of the barcode-based medication safety system was statistically significant (P=0.0045 and P=0.021 for errors and intercepted errors, respectively). CONCLUSIONS: Reforms intended to reduce medication errors were associated with substantial improvement.

Deviation from accepted drug administration guidelines during anaesthesia in twenty highly realistic simulated cases.

Deviations from accepted practice guidelines and protocols are poorly understood, yet some deviations are likely to be deliberate and carry potential for patient harm. Anaesthetic teams practice in a complex work environment and anaesthetists are unusual in that they both prescribe and administer the drugs they use, allowing scope for idiosyncratic practise. We aimed to better understand the intentions underlying deviation from accepted guidelines during drug administration in simulated cases. An observer recorded events that may have increased the risk of patient harm ('Events of Interest' [EOIs]) during 20 highly realistic simulated anaesthetic cases. In semi-structured interviews, details of EOIs were confirmed with participating anaesthetic teams, and intentions and reasoning underlying the confirmed deviations were discussed. Confirmed details of EOIs were tabulated and we undertook qualitative analysis of interview transcripts. Twenty-four EOIs (69% of 35 recorded) were judged by participants to carry potential for patient harm, and 12 (34%) were judged to be deviations from accepted guidelines (including one drug administration error). Underlying reasons for deviations included a strong sense of clinical autonomy, poor clinical relevance and a lack of evidence for guidelines, ingrained habits learnt in early training, and the influence of peers. Guidelines are important in clinical practice, yet self-identified deviation from accepted guidelines was common in our results, and all but one of these events was judged to carry potential for patient harm. A better understanding of the reasons underlying deviation from accepted guidelines is essential to the design of more effective guidelines and to achieving compliance.

The frequency and nature of drug administration error during anaesthesia in a Chinese hospital.

BACKGROUND: Throughout the world, drug administration error remains a known and significant threat to patients undergoing anaesthesia. Estimates of the extent of the problem vary, but few are based on large prospectively collected datasets. Furthermore, little is known about whether differences in work culture are important in error rates. METHODS: A prospective incident monitoring study was conducted at a large tertiary hospital in China to estimate the frequency of drug administration error during anaesthesia. Anaesthetists were asked to return a study form anonymously for every anaesthetic, indicating whether or not a drug administration error had occurred, including incident details if affirmative. RESULTS: From 24,380 anaesthetics, 16,496 study forms were returned (67.7% response rate), reporting 179 errors. The frequency (95% confidence interval) of drug administration error was 0.73% (0.63% to 0.85%) based on total study anaesthetics and 1.09% (0.93% to 1.26%) based on total forms returned. The largest categories of error were omissions (27%), incorrect doses (23%) and substitutions (20%). Errors resulted in prolonged stay in recovery for 21 patients, transfer to the ICU for five and one case each of haemorrhagic shock and asthmatic attack. More respondents who were not fully rested reported inattention as a contributing factor to error (21%) than those who were fully rested (7%, P = 0.04). CONCLUSION: Our results are comparable with other international prospective estimates indicating that drug administration error is of concern in China as elsewhere. These results will form a baseline from which to detect the effects of countermeasures.

Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study.

A safety-orientated system of delivering parenteral anaesthetic drugs was assessed in a prospective incident monitoring study at two hospitals. Anaesthetists completed an incident form for every anaesthetic, indicating if an incident occurred. Case mix data were collected and the number of drug administrations made during procedures estimated. From February 1998 at Hospital A and from June 1999 at Hospital B, until November 2003, 74,478 anaesthetics were included, for which 59,273 incident forms were returned (a 79.6% response rate). Fewer parenteral drug errors occurred with the new system than with conventional methods (58 errors in an estimated 183,852 drug administrations (0.032%, 95% CI 0.024-0.041%) vs 268 in 550,105 (0.049%, 95% CI 0.043-0.055%) respectively, p = 0.002), a relative reduction of 35% (difference 0.017%, 95% CI 0.006-0.028%). No major adverse outcomes from these errors were reported with the new system while 11 (0.002%) were reported with conventional methods (p = 0.055). We conclude that targeted system re-design can reduce medical error.

The influence of various graphical and numeric trend display formats on the detection of simulated changes.

Integration of a large amount of information is important in anaesthesia but there is little research to guide the development of data displays. Anaesthetists from two hospitals participated in five related screen based simulation studies comparing various formats for display of historical or 'trend' data. Participants were asked to indicate when they first noticed a change in each displayed variable. Accuracy and latency (i.e. delay) in detection of changes were recorded. Latency was shorter with a graphic display of historical data than with a numeric display. Increasing number of variables or reduction of y-axis height increased the latency of detection. If the same number of data points were included, there was no difference between graphical and numerical displays of historical data. There was no difference in accuracy between graphical or numerical displays. These results suggest that the way trend data is presented can influence the speed of detection of changes.

A new infusion syringe label system designed to reduce task complexity during drug preparation.

A new safety-orientated drug infusion label was studied and was compared with conventional methods by prospectively collecting incident reports from November 1998 to November 2003. Anaesthetists were asked to return an incident form for every anaesthetic (87% response rate), the vast majority indicating that no error had occurred. One error was reported with the use of the new label. However, this was due to an incorrect patient weight being recorded in the notes, and the dose was correct for the information available. Therefore, this data point was not included in the analysis. Seven errors were reported in the calculation of dosage using conventional infusion labels during 18 491 anaesthetics compared with no calculation errors in 10 655 anaesthetics with the new label (p = 0.045, Chi-squared test). Despite the difficulties of demonstrating significant benefit from safety initiatives in medicine, these data suggest that targeted system redesign can be effective inreducing error.

A national survey of infection control practice by New Zealand anaesthetists.

Anaesthetists have an important role in preventing nosocomial infection. Failures in this role have resulted in critical reports in the media. We ascertained the current practices of New Zealand anaesthetists relating to infection control, by distributing a questionnaire to all 450 anaesthetists practising in New Zealand. Sixty-one percent responded. Just over half the respondents had never read their hospital policy on infection control and over a third had never read the Australian and New Zealand College of Anaesthetists policy document on infection control. It was found that 3.4% rarely changed gloves if they became contaminated and 2.2% occasionally used the same syringe to administer drugs to more than one patient. The majority (86.3%) of respondents split one drug ampoule between more than one patient, 41.3% used multidose vials for more than one patient and 2.2% used pre-filled syringes for more than one patient. The majority complied with the College infection control policy for performing arterial cannulation (85.7%), central venous cannulation (77.4%) and regional blockade (65.1%). Respondents ranked the overall risk of the anaesthetist contributing to the transmission of infectious agents on a scale from 0 to 10 (10=highest risk). The median response was 7, the modal response was 10 and interquartile range was 4 to 8. There was a high level of awareness of the risks of contributing to cross-infection inherent in anaesthesia, most anaesthetists reporting that they followed recommended guidelines in this context. However, these data suggest more effort is required to promote compliance with appropriate guidelines.

The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals.

Safety practices in health care have not kept pace with the increasing complexity of medical technology. Although anaesthesia is generally considered to be a leader in the improvement of patient safety, more powerful safety strategies must be found and employed. From an analysis of system characteristics, the nuclear power industry is proposed as an alternative analogy for safety in anaesthesia, and a novel diagrammatic approach is developed for the conceptualisation of safety goals. The nuclear power industry has spent vastly more time and money than has health care on the development of safety, and has progressed through significant safety milestones approximately three times more quickly than has anaesthesia. The greatest scope for the improvement of safety in anaesthesia lies in the appropriate re-design of medical systems and the lowering of the threshold for the reporting of incidents to include accident precursors, thus allowing the identification of dangerous systems before accidents occur.

Transient fixation on a non-native language associated with anaesthesia.

We report a patient with the unusual language disturbance of transient fixation on a non-native language after otherwise uneventful general anaesthesia. The patient was unable to speak his native language for a period of 5-10 min, despite a desire to do so. He fully and spontaneously recovered from the episode. The phenomenon raises a number of interesting questions about the nature of human language, anaesthesia and consciousness. We discuss our patient in the context of some of these questions and present a review of three similar patients reported in the anaesthetic literature.

Evidence-based strategies for preventing drug administration errors during anaesthesia.

We developed evidence-based recommendations for the minimisation of errors in intravenous drug administration in anaesthesia from a systematic review of the literature that identified 98 relevant references (14 with experimental designs or incident reports and 19 with reports of cases or case series). We validated the recommendations using reports of drug errors collected in a previous study. One general and five specific strong recommendations were generated: systematic countermeasures should be used to decrease the number of drug administration errors in anaesthesia; the label on any drug ampoule or syringe should be read carefully before a drug is drawn up or injected; the legibility and contents of labels on ampoules and syringes should be optimised according to agreed standards; syringes should (almost) always be labelled; formal organisation of drug drawers and workspaces should be used; labels should be checked with a second person or a device before a drug is drawn up or administered.

A prospective, randomised clinical evaluation of a new safety-orientated injectable drug administration system in comparison with conventional methods.

Fifteen anaesthetists were observed while providing anaesthesia for 15 pairs of adult cardiac surgical operations, using conventional methods for one of each pair and a new drug administration system designed to reduce error for the other. Aspects of each method were rated by users on 10-cm visual analogue scales (10 being best). The new system was rated more favourably than conventional methods in terms of safety (median [range] = 8.1 [6.8-9.7] vs. 7.1 [2.6-9.3] cm; p = 0.001) and usability (8.5 [5.9-9.4] vs. 7.5 [3.2-9.8] cm; p=0.027). The new system saved preparation time both before anaesthesia (median [range] = 180 [32-480] vs. 360 [120-600] s; p=0.013) and during anaesthesia (10 [2-38] vs. 12 [10-60] s; p=0.009). Prefilled syringes for the new system increased costs by euro 23.00 per anaesthetic (p = 0.041), but this increase is likely to be offset by the potential of the new system to decrease costly iatrogenic harm by preventing drug error.

A prospective clinical audit of central venous catheter use and complications in 1000 consecutive patients.

We conducted a prospective audit of central venous catheter (CVC) use in 1000 consecutive patients to better define the rates of postoperative complications (particularly vascular perforation) and the pattern of CVC and pulmonary artery catheter (PAC) usage (particularly the number of lumens inserted and utilized). Details of CVCs, complications, and the number of lumens in place and used, were recorded daily until all CVCs were removed. A total of 1546 CVCs and 223 PACs were placed in study patients. Two non-fatal perforations occurred: a perforated right atrium in a patient who received an Arrow triple-lumen CVC (previously reported), and a perforated pulmonary artery in a patient upon withdrawal of a Baxter PAC. The risk per patient of any CVC-related perforation was 0.2% (95% confidence interval (CI): 0.02% to 0.7%). The rates of CVC-related sepsis and local infection were 3% (95% CI: 2% to 4%) and 2% (95% CI: 1% to 3%) respectively. At the peak of CVC use (day 1 in the ICU) the overall number of lumens placed was significantly correlated with lumens used (r = 0.53), endorsing clinical judgement in the anticipation of the needs of the patient. The modal number of lumen uses in adults and children was four. However, in children, fewer catheters were inserted per patient than in adults (1.28 vs 1.63, P = 0.01), and placed lumens were used more intensively (P < 0.001). Data appear to justify the routine selection of a triple-lumen CVC in adult patients, but not of a quad-lumen CVC.