MEDICATION ERROR IN ANAESTHESIAAndrew Smith, Lancaster, UK on behalf of the ESA/EBA Task Force Patient Safety

Adverse drug event ADEAn adverse drug event, injuries resulting from medical intervention related to a drug, includes both appropriate and inappropriate use of drugs." [Carlton G et al. Medication-related errors: a literature review of incidence and antecendents. Annu Rev Nurs Res 2006]

Synonyms in the literature Drug misadventures Drug related problems Drug related incident

The term comprises both Adverse drug reactions Medication errorsDEFINITIONS

Adverse drug reaction ADRAn adverse drug reaction is a response to a drug which is noxious and unintended and which occurs in man at doses normally used for prophylaxis, diagnosis or therapy of disease, or for modification of physiological function.[World Health Organization WHO, 2003]

Medication error"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; And use." [National Coordinating Counsel for Medication Error Reporting and Preventing NCC MERP, June 2008]DEFINITIONS

Side-effect: a known effect, other than that primarily intended, relating to the pharmacological properties of a medication e.g. opiate analgesia often causes nausea

Adverse reaction: unexpected harm arising from a justified action where the correct process was followed for the context in which the event occurred e.g. an unexpected allergic reaction in a patient taking amedication for the first timeDEFINITIONS

WHAT SORT OF ERRORS CAN OCCUR? Wrong drug Wrong patient Wrong route Wrong dose

ERROR PRONE PRESCRIPTIONSIllegible handwritingUsing misleading decimal places 1.0 mg instead of 1 mg .1 mg instead of 0.1 mgUse of abbreviations 2x (means 2 tablets or 2x daily ???)

Recommendations:Avoid trailing zeros e.g. write 1 not 1.0Use leading zeros e.g. write 0.1 not .1Know accepted local terminologyWrite neatly, print if necessary

HOW CAN PRESCRIBING GO WRONG?Inadequate knowledge about drug indications and contraindicationsNot considering individual patient factors, such as allergies, pregnancy, co-morbidities, other medicationsWrong patient, wrong dose, wrong time, wrong drug, wrong routeInadequate communication (written, verbal)Documentation - illegible, incomplete, ambiguousMathematical error when calculating dosageIncorrect data entry when using computerized prescribing e.g. duplication, omission, wrong numberWorld Health Organization WHO, Patient Safety Curriculum Guide

HOW CAN ADMINISTRATION GO WRONG?World Health Organization WHO, Patient Safety Curriculum GuideWrong patientWrong routeWrong timeWrong doseWrong drugOmission, failure to administerInadequate documentation

WHICH PATIENTS ARE MOST AT RISK OF MEDICATION ERROR?World Health Organization WHO, Patient Safety Curriculum GuidePatients on multiple medicationsPatients with another condition, e.g. renal impairment, pregnancyPatients who cannot communicate wellPatients who have more than one doctorPatients who do not take an active role in their own medication useChildren and babies (dose calculations required)

IN WHAT SITUATIONS ARE STAFF MOST LIKELY TO CONTRIBUTE TO A MEDICATION ERROR?World Health Organization WHO, Patient Safety Curriculum GuideInexperienceRushing, doing two things at onceInterruptionsFatigue, boredom, being on automatic pilot leading to failure to check and double-checkLack of checking and double checking (including two-person checking) habitsPoor teamwork and/or communication between colleaguesReluctance to use memory aids

THE 5-RSWorld Health Organization WHO, Patient Safety Curriculum GuideRight DrugRight RouteRight TimeRight DoseRight Patient

PHASES OF DRUG DEVELOPMENT AND PRECLINICAL AND CLINICAL TRIALS

THE MEDICATION USE PROCESS

AT WHICH STEP IN THE MEDICATION PROCESS DO ERRORS OCCUR?Bates et al., JAMA 1995, 274Prescription (hand written) 39%Administration38%Dispensation 11%Documentation 12%

SOUND ALIKE LOOK ALIKE Examples from Switzerlandhttp://www.patientensicherheit.ch/de/publikationen/Quick-Alerts.htmlSound alike and look alike drug names Generic nameTrade name Clonidin Catapresan Clomipramin AnafranilCodein Codein Knoll Etodolac LodinCotrimazol Bactrim, Cotrim, Nopil Clotrimazol Canesten, Corisol

Difficult to tell as many are not reported BUTEstimated frequencies are:1 in 572 anaesthetics (Yamamoto J Anesth 2008; 248-52)1 in 274 anaesthetics (Llewellyn Anaes Intens Care 2009; 37: 93)1 in 133 anaesthetics (Webster Anaes Intens Care 2001; 29: 494)

How many anaesthetics do you give every year?HOW FREQUENT IS MEDICATION ERROR IN ANAESTHESIA?

Death is uncommon but what happens if....Atracurium is given instead of midazolam?Cefuroxime is given instead of thiopentone?Metoclopramide is given instead of succinylcholine?Bupivacaine is given intravenously instead of epidurally?Fentanyl is given intrathecally instead of intravenously?Loss of expected effect and possible physical or psychological harm to the patientWHAT ARE THE CONSEQUENCES OF DRUG ERROR?

Standardised preparations and concentrations of drugs and infusionsAvoid boxes and ampoules of different drugs which look alikeLabel syringesTake care with predisposing factors - Organisation and tidiness of work spaces - Human factors such as fatigue and hasteCheck drug during preparation and before administration with two peopleHigh-tech solutions: bar code systems and computerised prescribingPREVENTING MEDICATION ERROR: KEY STRATEGIES

STANDARDISED SYRINGE LABELS

Ask the right question:

What drug is this?notThis is X, isnt it?

- So both people have to actively read and check the labelTWO-PERSON CHECKING

RECOMMENDATIONSUse generic names where appropriateTailor your prescribing for each patientLearn and practise thorough medication history takingKnow which medications are high-risk and take precautionsBe very familiar with the medication you prescribe and/or dispenseUse memory aidsRemember the 5 Rs when prescribing and administeringCommunicate clearlyDevelop checking habitsEncourage patients to be actively involved in the processReport and learn from medication errorsWorld Health Organization WHO, Patient Safety Curriculum Guide

Anaesthesia Patient Safety Foundation video on medication safety in the OR:

http://www.apsf.org/resources_video2.php

WHO safety curriculum (pdf included in this Starter Pack)Vincent C. Essentials of Patien Safety, pages 30-34 (pdf included in this Starter Pack)MORE INFORMATION

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