Partner Meeting

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

• 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

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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

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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
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WHAT SORT OF ERRORS CAN OCCUR?

• Wrong drug
• Wrong patient
• Wrong route
• Wrong dose

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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 zerose.g. write 1 not 1.0
• Use leading zerose.g. write 0.1 not .1
• Know accepted local terminology
• Write neatly, print if necessary

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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
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HOW CAN ADMINISTRATION GO WRONG?

• Wrong patient
• Wrong route
• Wrong time
• Wrong dose
• Wrong drug
• Omission, failure to administer
• Inadequate documentation

World Health Organization WHO, Patient Safety
Curriculum Guide
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WHICH PATIENTS ARE MOST AT RISK OF MEDICATION
ERROR?

• 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)

World Health Organization WHO, Patient Safety
Curriculum Guide
10
IN WHAT SITUATIONS ARE STAFF MOST LIKELY TO
CONTRIBUTE TO A MEDICATION ERROR?

• 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

World Health Organization WHO, Patient Safety
Curriculum Guide
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THE 5-RS

• Right Drug
• Right Route
• Right Time
• Right Dose
• Right Patient

World Health Organization WHO, Patient Safety
Curriculum Guide
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PHASES OF DRUG DEVELOPMENT AND PRECLINICAL AND
CLINICAL TRIALS
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THE MEDICATION USE PROCESS
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AT WHICH STEP IN THE MEDICATION PROCESS DO ERRORS
OCCUR?
Prescription(hand written) 39
Administration 38
Documentation 12
Dispensation 11
Bates et al., JAMA 1995, 274
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SOUND ALIKE LOOK ALIKE Examples from
Switzerland
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
http//www.patientensicherheit.ch/de/publikationen
/Quick-Alerts.html
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HOW FREQUENT IS MEDICATION ERROR IN ANAESTHESIA?
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?
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WHAT ARE THE CONSEQUENCES OF DRUG ERROR?

• 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

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PREVENTING MEDICATION ERROR KEY STRATEGIES

• 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

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STANDARDISED SYRINGE LABELS
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TWO-PERSON CHECKING
Ask the right question What drug is
this? not This is X, isnt it? - So both
people have to actively read and check the label
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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 Rs 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 Guide
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MORE INFORMATION

• 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)