Abstract PR581

Abstract

Background & Objectives: Errors in drug administration are quite frequent during anesthetic practice, with a reported rate of one in every 113-450 procedures. Although most events do not result in serious consequences, some can cause severe injury or even death. Several factors contribute to these faults, including the anesthesiologist’s experience, multitasking, medication’s appearance, severity of comorbidities and kind of surgery. Aims of this study were to determine the incidence and type of medication error among Brazilian anesthesiologists and to identify the common causal factors. Materials & Methods: After approval of national ethical committee a link to an online survey form was mailed to all 9,731 members of the Brazilian Anesthesiologists’ Society. After formal consent, they were asked to report, voluntarily and confidentially, aspects related to the medication error event, like type of surgery, time of the day and nature of the mistakes during anesthetic procedures. Results: One thousand thirty seven anesthesiologists replied this survey (10,6%). Most of the responders had between 30 and 39 years old (38,88%) and less than 5 years of anesthesiologist practice (23,69%). The frequency of the participants who had experienced at least one drug error was 74,43% and 89,51% had at least one “near miss”. The events were more frequent at general surgery and during the day. The most common incidents were changing ampoules (69.46%), syringe swap (40.54%), incorrect dose (26.62%), repeating the same drug previously infused instead of the desired (8.24 %), injection in a non recommended rate (8.11%) and use of a drug that was contraindicated for the patient (12.16%). Only 8.89% injected a medication in a different route (e.g. epidural, arterial). The most frequent mistake was the injection of midazolam 5mg/ml instead of midazolam 1mg/ml. Although most adverse events were of minor consequence (79,46%), eleven anesthesiologists had report deaths (n = 8) or irreversible damage (n = 3). The similarity between the ampoules (61,35%) and personal distraction (52,68%) were the most contributing factors for the occurrences. Approximately 2/3 of respondents think that label ampoules with standard colors can reduce the incidence of medication errors. Conclusion: Most anesthesiologists experienced at least one drug error or a near miss. The most frequent error was an exchange of ampoules due to their similarity. These findings support the creation of a national policy for reporting and prevention of medication errors.