MEDICATION ERROR IN ANAESTHESIAMEDICATION ERROR IN ANAESTHESIA

Andrew Smith, Lancaster, UK on behalf of the ESA/EBA Task Force Patient Safety

Andrew Smith, Lancaster, UK on behalf of the ESA/EBA Task Force Patient Safety

Adverse drug event ADE

“An 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 errors

DEFINITIONS

Adverse drug reaction ADR

“An adverse drug reaction is a response to a drug which is noxious and unintendedand 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 time

DEFINITIONS

WHAT SORT OF ERRORS CAN OCCUR?

• Wrong drug

• Wrong patient

• Wrong route

• Wrong dose

ERROR PRONE PRESCRIPTIONS

• Illegible handwriting

• Using misleading decimal places1.0 mg instead of 1 mg.1 mg instead of 0.1 mg

• Use of abbreviations2x (means 2 tablets or 2x daily ???)

Recommendations:• Avoid trailing zeros

e.g. write 1 not 1.0

• Use leading zerose.g. write 0.1 not .1

• Know accepted local terminology

• Write neatly, print if necessary

HOW CAN PRESCRIBING GO WRONG?

• Inadequate knowledge about drug indications and contraindications

• Not considering individual patient factors, such as allergies, pregnancy, co-morbidities, other medications

• Wrong patient, wrong dose, wrong time, wrong drug, wrong route

• Inadequate communication (written, verbal)

• Documentation - illegible, incomplete, ambiguous

• Mathematical error when calculating dosage

• Incorrect data entry when using computerized prescribing e.g. duplication, omission, wrong number

World Health Organization WHO, Patient Safety Curriculum Guide

HOW CAN ADMINISTRATION GO WRONG?

World Health Organization WHO, Patient Safety Curriculum Guide

• Wrong patient

• Wrong route

• Wrong time

• Wrong dose

• Wrong drug

• Omission, failure to administer

• Inadequate documentation

WHICH PATIENTS ARE MOST AT RISK OF MEDICATION ERROR?

World Health Organization WHO, Patient Safety Curriculum Guide

• Patients on multiple medications

• Patients with another condition, e.g. renal impairment, pregnancy

• Patients who cannot communicate well

• Patients who have more than one doctor

• Patients who do not take an active role in their own medication use

• Children 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 Guide

• Inexperience

• Rushing, doing two things at once

• Interruptions

• Fatigue, boredom, being on “automatic pilot” leading to failure to check and double-check

• Lack of checking and double checking (including two-person checking) habits

• Poor teamwork and/or communication between colleagues

• Reluctance to use memory aids

THE 5-R’S

World Health Organization WHO, Patient Safety Curriculum Guide

• Right Drug

• Right Route

• Right Time

• Right Dose

• Right Patient

PHASES OF DRUG DEVELOPMENT AND PRECLINICAL AND CLINICAL TRIALSPHASES 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, 274

Prescription

(hand written) 39%

Administration

38%

Dispensation

11%

Documentation

12%

“SOUND ALIKE – LOOK ALIKE” – Examples from Switzerland“SOUND ALIKE – LOOK ALIKE” – Examples from Switzerland

http://www.patientensicherheit.ch/de/publikationen/Quick-Alerts.htmlhttp://www.patientensicherheit.ch/de/publikationen/Quick-Alerts.html

Sound alike and look alike drug names

Generic name Trade name

Clonidin Catapresan

Clomipramin Anafranil

Codein Codein Knoll

Etodolac Lodin

Cotrimazol Bactrim, Cotrim, Nopil

Clotrimazol Canesten, Corisol

Sound alike and look alike drug names

Generic name Trade name

Clonidin Catapresan

Clomipramin Anafranil

Codein Codein Knoll

Etodolac Lodin

Cotrimazol Bactrim, Cotrim, Nopil

Clotrimazol Canesten, Corisol

Difficult to tell as many are not reported BUT

Estimated 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 patient

WHAT ARE THE CONSEQUENCES OF DRUG ERROR?

• Standardised preparations and concentrations of drugs and infusions

• Avoid boxes and ampoules of different drugs which look alike

• Label syringes

• Take care with predisposing factors

- Organisation and tidiness of work spaces

- Human factors such as fatigue and haste

• Check drug during preparation and before administration with two people

• ‘High-tech’ solutions: bar code systems and computerised prescribing

PREVENTING MEDICATION ERROR: KEY STRATEGIES

STANDARDISED SYRINGE LABELS

Ask the right question:

‘What drug is this?’

not

‘This is X, isn’t it?’

- So both people have to actively read and check the label

TWO-PERSON CHECKING

RECOMMENDATIONS

• Use generic names where appropriate

• Tailor your prescribing for each patient

• Learn and practise thorough medication history taking

• Know which medications are high-risk and take precautions

• Be very familiar with the medication you prescribe and/or dispense

• Use memory aids

• Remember the 5 R’s when prescribing and administering

• Communicate clearly

• Develop checking habits

• Encourage patients to be actively involved in the process

• Report and learn from medication errors

World Health Organization WHO, Patient Safety Curriculum GuideWorld 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