Medication errors in anesthetic practice in Brazil - an observational study.

Abstract

Introduction: There is increasing data collection in literature on errors in the drug administration chain. In anesthesiology, emergency and urgency situations favor errors in medications, however, it is not yet clear how some factors can impact the frequency of these errors. Objective: To evaluate the impact of knowledge of important concepts and fundamentals related to quality and safety in anesthesia in the practice of safe anesthesia as a factor to prevent errors with medications. Method: Observational study with participants of the 61st Brazilian Congress of Anesthesia. The volunteers responded to a semi-structured instrument with issues related to the whole process that could trigger medication errors. Results: A total of 337 volunteers (42.2% of Anesthesia Resident Physicians and 57.8% of Anesthesiologists) participated in the study. It was observed that 50.7% stated that eventually they had already injected wrong medications, with a significant difference (p <0.00) between the Anesthesia Resident Physicians (43.6%) and Anesthesiologists (56%). A greater number of working hours and greater number of hospitals in which they work caused higher percentages of professionals with medication errors. Among the professionals who reported they had eventually administered erroneous medications due to confusion with ampoules , 33.8% (n = 54) of those stated that they made a formal report of the adverse event with medications (ARP: 24.1% and MA: 39,2%). 96.9% (n = 155) found ampules of different medications (or concentrations thereof) in the same drug box (ARP) : 93.1%, MA: 99%) and 65.2% stated they have used the same syringe to prepare more than one anesthetic medication (ARP 75.9%, MA: 59%). Conclusions: The percentage of medication errors was significant and it is evident the need to implement policies that will guide the organization, distribution, allocation and use of medications in the surgical center.