REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiology www.sba.com.brMISCELLANEOUS
Profile
of
drug
administration
errors
in
anesthesia
among
anesthesiologists
from
Santa
Catarina
Thomas
Rolf
Erdmann
∗,
Jorge
Hamilton
Soares
Garcia,
Marcos
Lázaro
Loureiro,
Marcelo
Petruccelli
Monteiro,
Guilherme
Muriano
Brunharo
HospitalGovernadorCelsoRamos,Florianópolis,SC,Brazil
Received19April2014;accepted26June2014 Availableonline30November2015
KEYWORDS
Medicalerrors; Drugerrors; Anesthesiology; Anesthesia
Abstract
Introduction:Anesthesiologyistheonlymedicalspecialtythatprescribes,dilutes,and admin-istersdrugswithoutconferralbyanotherprofessional.Addingtothehighfrequencyofdrug administration,apropitiousscenariotoerrorsiscreated.
Objective: Accesstheprevalenceofdrugadministrationerrorsduringanesthesiaamong anes-thesiologists from Santa Catarina, the circumstances in which they occurred, and possible associatedfactors.
Materialsandmethods: An electronic questionnaire was sent to all anesthesiologists from SociedadedeAnestesiologiadoEstadodeSantaCatarina,withdirectormultiplechoice ques-tionsonresponderdemographics andanesthesiapracticeprofile;prevalenceoferrors,type andconsequenceoferror;andfactorsthatmayhavecontributedtotheerrors.
Results:Oftherespondents,91.8%reportedtheyhadcommittedadministrationerrors,adding thetotalerrorof274andmeanof4.7(6.9)errorsperrespondent.Themostcommonerrorwas replacement(68.4%),followedbydoseerror(49.1%),andomission(35%).Only7%of respon-dentsreportedneuraxialadministrationerror.Regardingcircumstancesoferrors,theymainly occurredinthemorning(32.7%),inanesthesiamaintenance(49%),with47.8%withoutharmto thepatientand1.75%withthehighestmorbidityandirreversibledamage,and87.3%ofcases with immediateidentification.Asfor possiblecontributingfactors,themostfrequent were distractionandfatigue(64.9%)andmisreadingoflabels,ampoules,orsyringes(54.4%).
Conclusion: Mostrespondentscommittedmore thanoneerrorinanesthesiaadministration, mainlyjustifiedasadistractionorfatigue,andoflowgravity.
© 2014SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
∗Correspondingauthor.
E-mail:thomaserdmann@hotmail.com(T.R.Erdmann). http://dx.doi.org/10.1016/j.bjane.2014.06.011
PALAVRAS-CHAVE
Errosmédicos; Errosdemedicac¸ão; Anestesiologia; Anestesia
Perfildeerrosdeadministrac¸ãodemedicamentosemanestesiaentre
anestesiologistascatarinenses
Resumo
Introduc¸ão:Aanestesiologiaéaúnicaespecialidademédicaqueprescreve,diluieadministraos fármacossemconferênciadeoutroprofissional.Somando-seaaltafrequênciadeadministrac¸ão defármacos,cria-seocenáriopropícioaoserros.
Objetivo:Verificaraprevalênciadoserrosdeadministrac¸ãodemedicamentosdurante aneste-sia,entreanestesiologistascatarinenses,ascircunstânciasemqueocorreramepossíveisfatores associados.
Materiaisemétodos:Umquestionárioeletrônicofoienviado atodososanestesiologistasda SociedadedeAnestesiologiadoEstadodeSantaCatarinacontendorespostasdiretasoude múlti-plaescolhasobredadosdemográficoseperfildapráticaanestésicadoentrevistado;prevalência deerros,tipoeconsequênciadoerro;efatoresquepossivelmentecontribuíramparaoserros.
Resultados: Dosentrevistados,91,8%afirmaramtercometidoerrodeadministrac¸ão,somando total deerros de274 emédia de4,7 (6,9) errospor entrevistado.Oerro maiscomum foi substituic¸ão(68,4%),seguidoporerrodedose(49,1%)eomissão(35%).Apenas7%dos entre-vistadosreferiramerrosdeadministrac¸ãononeuroeixo.Quantoàscircunstânciasdoserros, ocorreramprincipalmente noperíodomatutino(32,7%), namanutenc¸ão daanestesia(49%), com47,8%semdanosaopacientee1,75%commaiormorbidadecomdanoirreversíveleem 87,3%doscasosaidentificac¸ãoimediata.Quantoaospossíveisfatorescontribuintes,osmais frequentesforam:distrac¸ãoefadiga(64,9%)eleituraerradadosrótulosdeampolasouseringas (54,4%).
Conclusão:A maioria dos anestesiologistas entrevistados cometeu mais de um erro de administrac¸ão em anestesia,principalmente justificadocomo distrac¸ãoou fadiga,de baixa gravidade.
©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Drugadministrationerrorsareimportantcausesofmorbidity andmortality,1,2accountingforabout7000deathsperyear
inthe United States,3 resulting indirect health costsand
possiblyavoidablehuman suffering.2 Anesthesiologyisthe
onlymedicalspecialtythatprescribes,dilutes,and adminis-tersdrugswithoutconferralbyanotherprofessional.Adding tothehighfrequencyofdrugadministration,aswellasits potencyandapplicationurgency,itcreatesafavorable set-tingfor errorsandtothedisastrousconsequencesofsuch failure.
Thus,thereareseveralstudiesreportingdrug administra-tionerrorsasanimportantcauseofanestheticmorbidityand mortality.Ina1984study,evaluatinganesthesiaincidents, themostfrequentlyreportedwererespiratorysystem shut-downandneedleExchange.4Inanotherstudyperformedin
Denmarkofdeathsrelatedtoanesthesia,medicationerrors werethesecond leadingcause,secondonlytoairwayand ventilation problems. When associated with deaths from medicationerrorsandinfusionpumpproblems,theybecome thestudyleadingcauseofmortality.5
Overthepast60years,manystudieshaveassessedthe prevalenceofdrugadministrationerrorin anesthesia,but prospectiveworks designedspecifically tostudy the issue aroseonlyinthelastdecade.6---10 Suchworksreported
inci-dencesrangingfromoneerrorforeach133---450anesthesia applications. Considering the higher incidence, it was
estimatedthateachanesthesiologistmakessevenmistakes a year and consequently causes damage in two patients overacareer.2
Thus,togetherwiththegrowing interestinissues con-cerning thepatientsafetyduringanesthesia, itisofgreat valuetoexaminetheprevalenceofmedicationerrorsamong anesthesiologistsinSantaCatarina,aswellasthe verifica-tionofthefactorsthatcontributetotheerror.
Objective
Checkthe prevalenceofdrugadministrationerrorsduring anesthesia among anesthesiologists in Santa Catarina, as wellasthecircumstancesinwhichtheyoccurred,andassess thepossibleassociatedfactors.
Method
errors,type,detection time,andworst consequence of a committederror.The lastsection investigatedthe factors thatmayhavecontributedtotheerror.
The questionnairewassentby e-mailtwice,with four-week interval, together with an explanatory text on the researchnature,subjectrelevance,andinformedconsent for the use of data to all associated anesthesiologists of the Society of Anesthesiology of the Stateof Santa Cata-rina(SAESC)intheyear2013.Participationinthestudywas voluntaryuponacceptanceofthetermssentviaemail.
Thesoftwareusedforsendingthequestionnaireand stor-ageofresponseswastheSurveyMonkeyandforstatistical analysisandchartpreparation,MicrosoftExcelwasused.
Results
The questionnaire wassentto membersof the Anesthesi-ology Society of the State of Santa Catarina in July and August2013,30daysapart.Ofthe376membersofSAESC, 61answeredthequestionnaire,andtheresponseratewas 16.2%.
Regarding demographic data,the mean age of respon-dents was39 (standard deviation, 10.8) years, and80.3% were male. The mean working time with anesthesiology including residency training was 13 (10.6) years, and the meanweeklyworkinghourswas59(20.1)hours.Asfor spe-cialization,only16.4%werestillattendingresidency,45.9% hadanaesthesiologyexperttitle,and37.7%hadasuperior titleinanesthesiology.
AsshowninFig.1,91.8%ofrespondentssaidtheyhave committedadrugadministrationerror,withatotalnumber of 274 errors and a mean error of 4.7 (6.9) per intervie-wee. The most common type of error was replacement, committedby68.4%ofrespondents,followedbydoseerror (49.1%)andomission(35%).Withregard toneuraxialdrug administration error, only 7% of respondents reported its occurrence.Fig.2showserrortypesandpercentages.
Asforthecircumstancesinwhichtheerrorsoccurred,the majorityreportedtohaveoccurredinthemorning(32.7%), followed by the afternoon (21.8%) and evening (16.3%) periods.However,29%ofrespondentsdidnotrememberthe timetheerroroccurred.Mostoftheerrorsoccurredduring
8%
92%
Yes No
Figure 1 Prevalence of drug administration error among SantaCatarinaanesthesiologists.
0% 10%20%30%40%50%60%70% 80%
Incorrect route (administration of a drug by another route)
Incorrect dose (unwanted concentration, amount or infusion rate) Insertion (drug administered in unwanted
time)
Replacement (administration of a drug different from the intended one) Repetition (readministration of a drug due
to prior administration uncertainty)
Omission (a forgotten/non-administered drug or…)
Figure2 Typesoferrorsandprevalence.
0% 10% 20% 30% 40% 50% 60% 70% Other
Inadequated communication among anesthesiologists
Programming or malfunction of pumps Improper storage
Lack of knowledge or experience with the drug
Misreading of label/vial
Pressure to perform the procedure
Distraction/fatigue
Figure3 Factorsthatrespondentsbelievedhadcontributed totheerrors.
maintenance of anesthesia (49%), followed by the induc-tionofanesthesia(30.9%)andextubation(12.7%)periods.A minorityofrespondentsreportedhavingcommittederrors inthepreanesthetic(5.5%)orpostanesthetic(1.8%)periods. Regardingthe worst consequence of anerror, 47.8% of thosewhomademistakes reportedthattheerrorsdidnot bringharm to the patient, 43.9% reported less morbidity withreversibledamage,withincreasedtimetoextubation orpostanestheticrecovery.Highermorbiditywithreversible damagerequiringinvasivemonitoringwasreportedby7%of respondents,andhighermorbiditywithirreversibledamage wasreported by only one respondent (1.75%). No deaths were reported. For 87.3% of respondents who had made mistakes,theerroridentificationwasimmediate.
Regardingthepossiblefactorsthatrespondentsbelieved hadcontributedtotheerrors,themostcommonwere: dis-tractionandfatigue(64.9%),misreadingthelabelsofvialsor syringes(54.4%),pressuretoperformtheprocedure(21%), andimproperstorage(19%),asshowninFig.3.
Discussion
Thisstudyshowedthattheabsolutemajorityof anesthesiol-ogistshavecommittedadrugadministrationerror,andsome ofthemalreadycommittedmorethan oneerror. Notably, mostoftheseerrorsbroughtlittleconsequenceandlow mor-bidity,withnoreportofdeath.Thisresultisinagreement withtheliteratureonthesubject. Thisisacomplexissue and,assuch,difficulttostudy,withagreatvarietyoftypes ofstudiesonthesubjectandfewprospectivestudies.
ACanadianstudy,withadesignsimilartothis,reported that 85% of that country anesthesiologists have commit-ted an error or ‘‘quasi error’’, with four cases of death reported as a direct consequence of drug administration error,althoughmostofthemdidnotresultinmorbidity.11
formonitoringincidents,reportingthat itwas7%and10% ofallincidentsreported.12,13Inanotherstudywithsimilar
method,thisincidencewas21%of reportedincidentsand 0.36%regardingthenumberofanesthesiaintheperiod,but thestudyalsoincludedsideeffectsanddrugreactions.7
Inprospectivestudies,the commonlyusedmethodisa prospectivemonitoringofincidentsinwhich,forany anes-thesiaperformed,thereisaformthatmustbefilled(even negatively) and handed at the end of surgery. In these studiesthereis reallyadenominatorandtheincidenceof errorsmaybemoreaccuratelydetermined.Thehighest inci-dencereportedinaNewZealandstudy6was0.75%,orone
errorfor every133anesthesiaapplications,muchlikethe resultsofarecentChineseprospectivestudy9reportingan
incidenceof 0.73%, or one error for each 136 anesthesia applications.
In ourstudy,the mostcommon typeof errorwasdrug replacement, followed by incorrect dose and omission. Olderstudiesassumethatanerroroccurswhenthewrong drugordoseisgiven,11,12,14andothertypesoferror,suchas
omissionand incorrectroute ofadministration, were con-sideredonlyinmorerecentstudies.Thereisnodoubtthat these three types of error are the most common, how-ever,itsincidencevarieswiththestudies.Inmoststudies, replacement errors are the most frequent.6,8 In a
multi-centerstudy byLlewellyn etal.,it isinteresting thatthe replacementerrorswere morecommon whenaggregating the data for the three participating hospitals; however, whendata fromthe pediatrichospital areevaluated sep-arately,doseerrorsareasfrequentasreplacement.8 This
finding probably reflects the wide variations in weight amongpediatric patients, requiring frequent and unusual dilutions.
Incontrasttootherprospectivestudies,themost com-monerrorreportedbyZhangetal.9wasomission.Thisresult
is perhaps what most reflects the reality, given the high possibilityof memorybiasinvolving omissions:ifthedrug dose hasbeen forgotten, itis unlikely that theindividual remembertoreportit.
Inaccordancewithmostprospectivestudies,8,9ourstudy
showedthatmostoftheerrorsoccurduringmaintenanceof anesthesiabecausethisisthelongestperiodofanesthesia, inwhichmostofthedrugisadministeredorsimplybecause thisisatimewhenmonitoringisdecreased.9Thedayperiod
mostcommonlyreportedfortheoccurrenceoferrorswere matutinalandvespertine.Only16%oftheerrorsoccurredat night,thoughpossiblyanevensmallerfractionofsurgeries occurredinthisperiod.
Fatigue,hastiness,andinattentionundermine the abil-ityofanesthesiologiststomonitoractionsinwhichtheyare extremelyskilledandusuallypaynoattention.Thus, simi-larvialsor syringesareinterpretedascorrectandapplied wrongly, a well-known failure of the cognitive process.12
Fatigueanddistractionwerethecontributingfactorsmost frequentlycitedbyrespondents.Inaninitialassessment,in additiontothehigh workloads citedby respondents,it is easytoconcludethattheresultingfatiguefromoverwork makesthegapsincognitiveprocessmorelikely,leadingto theerrorand,consequently,toatendencyofanindividual errorapproach.
However, on further analysis, based on a work by Reason15andreviewbyWheeleretal.,16wenotethatthere
are organizational and administrative latent conditions that contribute to the error. Factors such as the lack of standardization of ampoules, labels, pharmacological presentation, andinfusionpump softwares,aswellasthe division of work that allows endless working hours and pressuretoproduce.15,16
Withthisinmind,itisworthnotingthatinourworkthe other contributingfactorscitedby respondentswere mis-readingthelabelsofvialsorsyringes,pressuretoperform theprocedure,andimproperstorage,allofwhichare associ-atedwithlatentconditionsandnotonlywiththeindividual. Thus,theerrorapproachmustalsoincludethesystem, tak-ingintoaccountthatphysicians areattheend ofa chain andonlypartofasystematicfailure.15,16
Althoughnotevaluatedinthisstudy,thepharmacological class generally more involved in the errors are the neu-romuscular blockers.7,14 This is a worrying fact given the
devastatingconsequences ofits unwantedadministration, especiallyinawakepatients.ANorwegianstudyestimated thatapatientreceivesneuromuscularblockerseverythree monthswhileawake.14Thepossibleexplanationisdrugthe
storagein5mLsyringes,asmostopioids,7aswellasitsuse
throughoutanesthesia.
Timely,itisworthnotingthatthehighincidenceoferrors inanesthesiologycontrastswiththelowincidenceof mor-tality and irreversible morbidity.14 In our study,only one
anesthesiologistreportedirreversibledamageandtherewas no report of death. Still, most anesthesiologists reported thattheerrordetectionwasimmediate.Thefactthatthe drugs used in anesthesia cause significant and immediate physiologicalchanges,combinedwiththespecialty charac-teristicmonitoringandconstanttrainingincriticalevents, mightexplainthisfinding.
Asthisisaproblemwithrareunfavorableoutcome,but potentially catastrophic,itmaybedifficulttostatistically provetheeffectivenessofeachsafetymeasure.Itisworth mentioning a study that reported a tendency to overall reductionoferrorswiththeuseofcoloredlabels,althoughit hasnotreachedstatisticalsignificance.Asignificant reduc-tion of errors involving only an exchange of ampolas was observed.14 Wemust remember thattheaviation industry
isaglobal securitymodel,andthatthepracticesadopted toreduce morbidityandmortalitywerenotbasedon evi-dence.Logicalandpracticalmeasureswereestablishedand asafetyculturewascreated.13,17
This study has some limitations. First, this is a cross-sectional study and it is only possible to calculate the prevalenceoferrorswithlowlevelofevidence.Moreover, theresponseratewaslowevenwhencomparedtosimilarly designedstudies,11probablyduetotheuseoftheinternet
tosendthequestionnaire,assuchcommunication vehicle probablyinspireslesscommitmenttotheresearch.
habits such as proper labeling and conference, such as institutional, with standardization of ampoules, syringes andlabels,useofbarcodeandcolors,evenifnotbasedon evidence, inorder toreduce to aminimum the potential forerrorandcreateasafetycultureinanesthesiology.
Conclusion
Mostrespondents made morethan one anesthesia admin-istrationerror,mainlyjustifiedasa distractionor fatigue, withlowincidenceofmajorconsequences.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Appendix
1.
Questionnaire
1. Whatisyourage?(years) 2. Whatisyoursex?(M/F)
3. Howlongdoyou workwithanesthesia(including resi-dency)?(years)
4. Howmanyhoursdoyouworkaweek? 5. Whatisyourlevelofexpertise?
Residencyinprogress
Anesthesiologist(specialisttitle) SuperiortitleinAnesthesiology
6. Haveyouevercommittedamedicationerror?(yes/no) 7. Howmanytimeshaveitoccurred?
8. Whatkindofmistakeshaveyoucommitted? Omission(aforgotten/non-administereddrug) Repetition(re-administrationofadrug)
Replacement (administration of a drug different fromtheintendedone)
Insertion(drugadministeredinunwantedtime) Incorrectdose (unwanted concentration, amount orinfusionrate)
Incorrectroute
9. Didsomefactorbelowcontributedtotheerror? Distractionorfatigue
Pressuretoperformtheprocedure
Misreadingoflabel/vialorsimilarcontainer Lackofknowledgeorexperiencewiththedrug Improperstorage
Incorrectprogrammingor malfunction ofinfusion pump
Inadequate communication among anesthesiolo-gists
Otherorunspecified
10. Someofyourmistakesoccurredbyincorrectneuraxial drugadministration?(yes/no)
11. Whatwastheworstconsequenceofanadministration errorofyours?
Nodamage(errorresultedinnochangeinthe anes-thesiaplanorincreasedrecoverytime)
Minormorbiditywithreversibledamage(increased timetoextubationorpost-anesthesiarecovery) Majormorbiditywithreversibledamage (invasive monitoringrequiredforerrorcorrection)
Majormorbiditywithirreversibledamage (myocar-dial infarction, heart failure, or permanent neurologicalsequelae)
Death
12. Inwhatshiftofthedaythemostseriouserroroccurred? Matutinal
Vespertine Nightly
Idonotremember
13. Whenintheperioperativeperioddidyourmostserious mistakeoccurred?
Preanesthetic
Inductionofanesthesia(orearlyintraoperative) Maintenanceofanesthesia
Extubation(ormomentsbeforeextubation) Postoperative
14. Howlongdidittakeyoutoidentifyyourmostserious mistake?
Immediateidentification Lateidentification
Suspectederror,unconfirmed
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