Why do Anesthesiologists Drug Administration Errors?

Medication error represents a particular challenge for the patient safety in tertiary care. Anesthesiologists should attempt against errors because they represents the unique medical specialty that administrate the drug without another professional conference, easily acting as vectors of adverse events during anesthesia [1]. Some factors expose more than others the susceptibility to undesirable events. This review has the purpose to define the main characteristics of drug administration errors in anesthesia practice. Mesh terms “medication errors”, “anesthesia” and “anesthesiologists” were combined during the search for studies used in this review. Anesthesiologists errs during the whole perioperative period, but most cases tend to happen in the morning, at the beginning of anesthesia, with no harm, by in-training providers in all types of surgeries and patients. Errors as incorrect dose and substitution due to distraction and fatigue are more common. Some routines should be incorporated to the experience of the anesthesiologist to facilitate the correct practice. Received: August 02, 2016; Accepted: September 06, 2016, Published: September 09, 2016 *Corresponding author: Thomas Rolf Erdmann, MD, Anesthesiologist Professor, Department of Surgery, Federal University of Santa Catarina, Professora Maria Flora Pausewang street, PO Box 88036-800, Florianópolis, Brazil, Tel: +554-832-0681-83; Fax: +55 48 3721-8354; E-mail: [email protected] Special Issue: Anesthesia & Critical Care event as patient harm or injury due to administration of a drug [6]. The steps of the administration process include requesting medication from pharmacy, dispensing the medication from the pharmacist to the anesthesiologist, preparing the medication (e.g., aspiration, dilution), administering the drug to reach the patient, documenting in the anesthesia information management system and monitoring the vital signs or patient exams after the administration [3]. According to the working system, errors can be divided in active failure, caused by people in direct contact to the patient, and latent condition, due to the system. Also, errors can be classified as due to omission (failure to perform an appropriate action) and commission (perform an inappropriate action) [7]. At most cases, medication errors occurs at administration stage (53%), followed by prescription (17%), preparation (14%) and transcription (11%) [8]. Some factors expose more than others the susceptibility to undesirable events. Leading the causes in anesthesia, medication errors far exceeds disconnection of the breathing circuit, the second cause of adverse events [9]. This review has the purpose to define the main characteristics of drug administration errors in anesthesia practice. Mesh terms “medication errors”, “anesthesia” and “anesthesiologists” were combined during the search for studies used in this review. Related studies to them were also used. Type of Errors Errors like syringe swaps, drug ampoule swaps, overdose or incorrect drug choices were cited [10,11], but were also found more detailed as 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 indented one), repetition (readministration of a drug due to prior administration uncertainty) and omission (a forgotten/nonadministered drug) [1]. Different results were observed in the studies. In Orser, et al. [10] self-reports study; the commonest cited errors were syringe Purpose Medication error represents a particular challenge for the patient safety in tertiary care. The overall rate is observed in order of 4.87 errors per 100.000 administrations by pharmacists [2]. Anesthesiologists should attempt against errors because they represents the unique medical specialty that administrate the drug without another professional conference, easily acting as vectors of adverse events during anesthesia [1]. Drug administration demands whole attention in the perioperative period, but not always respected in anesthesia practice. In a recent study, adverse events occurs in 1 of 3 anesthetics, medication error in 1 of 2 anesthetics and one of them in 1 of 20 perioperative medication administration [3]. One estimation shows that each anesthesiologist errs seven times a year and causes damage to patients twice over a career [4], representing high and unacceptably common situations. Medication error is defined as a failure to execute an action in the drug administration process or the use of an incorrect plan or action to achieve a patient care aim [5] and an adverse drug