Anesthesia-related medication error: time to take action.

Abstract

Listen

Translate article

cause significant clinical, financial and legal costs to patients and the health care system.1 To improve patient safety, each medical and surgical discipline needs to identify the sources of error and develop evidence-based preventative strategies. In this issue of the Journal, two reports remind us that medication errors are an ongoing challenge for patients undergoing anesthesia. Strock and colleagues describe paralysis of an awake patient resulting from the mislabelling of a pre-filled syringe that was prepared in a hospital pharmacy.2 Murdoch et al., report a near-miss incident resulting from the stocking of look-alike bottles that contain different concentrations of nitroglycerine in the labour suite.3 Indeed, a recent report by the National Health Service (NHS) of the United Kingdom entitled Building a safer NHS for patients: improving medication safety, suggests that the risk of serious drug errors is greater in anesthetic practice than other specialties.4 Recommendations in the NHS report aimed at improving drug safety in anesthetic practice are summarized in the Table. Is there evidence to support the claim that the potential for serious drug error is highest in anesthetic practice? The incidence of medication error during anesthesia is uncertain; however, a prospective study of 55,426 procedures reported that drug errors occurred in 63 cases (0.11%).5 Another study of 7,794 patients reported that the incidence of a drug administration error was 0.75%.6 Most anesthesiologists reported being involved in at least one drug error although most of the errors were inconsequential.7 The incidence of drug error is astonishingly low given the millions of drugs administered during anesthetic care. Nevertheless, the potential for harm is great, considering the potency of anesthetic drugs, the fast-pace of the operating room and multi-tasking by anesthesiologists. Outcome studies such as analyses of closed malpractice claims are important sources of information about adverse events. A recent analysis by the Canadian Medical Protective Association (CMPA) suggests that medication errors are the leading cause of adverse anesthetic-related events. The CMPA (www.cmpa-acpm.ca) generously provided the following information in its effort to improve patient safety and reduce liability for anesthesiologists. CMPA is a medical-legal defense organization for physicians who practice in Canada. It is funded and operated 756 EDITORIAL