Drug errors from the Thai Anesthesia Incidents Monitoring Study: analysis of 1,996 incident reports

Abstract

Background: The Royal College of Anesthesiologists of Thailand arranged the Thai Anesthesia Incidents Monitoring Study (Thai AIMS) to investigate the clinical course, outcome, contributing factors, and suggested preventive strategies for anesthesia related adverse events including drug errors. Methods: As part of the Thai AIMS, perioperative anesthesia incident reports of adverse events were collected on an anonymous and voluntary basis from 51 participating hospitals across Thailand between January 1 and June 30, 2007. Three anesthesiologists reviewed relevant data of drug error incidents. A descriptive statistics was used. Results: Among 1,996 incident reports of the Thai AIMS database, there were 82 incidents of drug errors (4.1%). Most of drug errors incidents occurred in maintenance phase (57.3%), general anesthesia (87.8%), and in the operation theatre (91.5%). One-fifth of incidents occurred under emergency condition (95%). Common anesthetic drugs involved were nondepolarizing neuromuscular blocking agent (23.1%), opioids (21.9%), antibiotics (17.1%), succinyl choline (7.3%), and induction agents (6.1%). Giving the wrong drug (35.4%), overdosage of drug (32.9%), problems with labeling (14.6%), and wrong concentration (9.8%) were the most common types of drug errors. Of the 25 substitutions with 14 syringe swap (17.1%) and six-ampule swap (7.3%), 60% involved a different pharmaceutical class of drug. Only 10.9% of incidents resulted in intubation, mechanical ventilation, or unplanned admission to intensive care unit. Seventy-nine point two percent were considered as preventable and 39% were due to system error. Haste (42.7) was considered as the most common contributing factors while vigilance (72%) and having experience (30.5%) were considered as common factors minimizing medication errors. Conclusion: Practice guidelines especially using of class specific color labeling, quality assurance activity, improvement of communication, and training were suggested preventive strategies. Keywords: Adverse event, anesthesia, complication, drug error, medication error, substitution