Syringe Swap Research Articles

A sudden death with lung embolism after inadvertent infusion of zinc oxide shake lotion

A 74-year old woman in postoperative treatment after a colonic surgery died immediately after perfusion of about 1.5 mL of a white emulsion which was believed to contain 1% propofol via cardiac catheter into the right atrium. It was strongly suspected that a syringe with a zinc oxide shake lotion (consisting of 20% ZnO, 20% talc, 25% glycerol and 35% water) which was intended for external treatment had been mistaken for the propofol syringe. During autopsy, an anatomic cause of death could not be found. In order to exclude an intoxication and to determine the significance of the perfusion fluid in this context, toxicological and histological investigations were performed. Propofol and other drugs applied to the patient were found in therapeutic or sub-therapeutic range. However, in comparison to a control case, the zinc concentrations determined by AAS were about 200 times higher in lung tissue, 10 times higher in heart blood and 3–4 times higher in kidney and liver tissue. No increase was seen in venous blood. Histology showed a strong embolism of the lung tissue with birefingent sharp-edged crystals, which were identified as the talcum, and an amorphous component (ZnO). The same embolism was seen to a medium extent also in the brain sections and to a low extent in heart, liver, pancreas and kidney. Pulmonary embolism by talcum and zinc oxide was established as the cause of death which occurred by syringe swap due to insufficient security precautions in the drug administration. The results are discussed in context of pulmonary microembolism cases frequently described for drug addicts after injection of crashed talcum containing tablets.

Drug administration errors by South African anaesthetists--a survey.

To investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists. A confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists. A total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard. Most anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a 'syringe swap' involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents.

Color-Coded Syringes to Reduce the Incidence of Syringe Swaps

Color-Coded Syringes to Reduce the Incidence of Syringe Swaps

Crisis management during anaesthesia: awareness and anaesthesia

Background: Patient awareness during general anaesthesia has considerable potential for severe emotional distress in the patient as well as professional, personal, and financial consequences for the anaesthetist. Objectives: To examine...

Colour coding prefilled syringes

After the successful adoption of the International Colour Coding System for user-applied syringe labels [1], the prefilled syringes of succinylcholine, ephedrine and atropine are now the odd members of anaesthetists' armamentarium. In addition to the label, the colour, shape and size of syringes play a major role in identifying the right syringe, especially in an emergency situation [2]. Therefore, as an extra cue to avoid human error, we feel strongly that the colour of the casing and the plunger of these prefilled syringes should be changed to comply with the International Colour Coding of syringe labels. Becton Dickinson in Australia (BD – Australia/New Zealand, North Ryde, NSW, Australia) is leading the way by providing a 5 ml syringe with a fluorescent red plunger [3] to be used for muscle relaxants. Since succinylcholine is one of the commonest drugs implicated in syringe swap incidents [4], we urge the manufacturers in the UK to consider the same for succinylcholine, if not for all muscle relaxants.

Use of Colored Syringes Reduces the Incidence of Syringe Swap During Anesthesia

Use of Colored Syringes Reduces the Incidence of Syringe Swap During Anesthesia

Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database

Eight hundred and ninety-six incidents relating to drug error were reported to the Australian Incident Monitoring Study. Syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labelled but given in error, and 187 (20.8%) due to selection of the wrong ampoule or drug labelling errors. The drugs most commonly involved were neuromuscular blocking agents, followed by opioids. Equipment misuse or malfunction accounted for a further 234 (26.1%) incidents; incorrect route of administration 126 (14.1%) incidents; and communication error 35 (3.9%) incidents. The outcomes of these events included minor morbidity in 105 (11.7%), major morbidity in 42 (4.7%), death in three (0.3%) and awareness under anaesthesia in 40 (4.4%) incidents. Contributing factors included inattention, haste, drug labelling error, communication failure and fatigue. Factors minimising the events were prior experience and training, rechecking equipment and monitors capable of detecting the incident. The information gained suggests areas where improved guidelines are required to reduce the incidence of drug error. Further research is required into the effectiveness of preventive strategies.

Drug related critical incidents

Drug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect/drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.

Avoiding inadvertent epidural injection of drugs intended for non-epidural use.

Inadvertent administration of non-epidural medications into the epidural space has the potential for serious morbidity and mortality. The aim of this study was to collate reported incidents of this type, describe the potential mechanisms of occurrence and identify possible solutions. We searched medical databases and reviewed reference lists of papers retrieved, covering a period of 35 years, regarding this type of medication incident. The 31 reports of 37 cases found is likely to represent a gross underestimation of the actual number of incidents that occur. "Syringe swap", "ampoule error", and epidural/intravenous line confusion were the main sources of error in 36/37 cases (97%). Given that no effective treatment for such errors has been identified, prevention should be the main defence strategy. Despite all the precautions that are currently undertaken, accidents will inevitably occur. We have identified areas for systemwide change that may prevent these types of incidents from occurring in future.

Fatigue in anesthesia: implications and strategies for patient and provider safety.

HEALTHCARE delivery takes place 24 h a day, 7 days a week, and is colloquially termed a “24/7” operation. Anesthesia providers are required to deliver critical around-the-clock care to a variety of patients. This parallels the situation in many other domains that provide such services, e.g., transportation, law enforcement, communications, fire fighting, technology, manufacturing, and the military. Even “convenience” industries (e.g., gas stations and grocery stores) now provide uninterrupted access. These continuous operational demands present unique physiologic challenges to the humans who are called on to provide safe operations within these systems. Human physiologic design dictates circadian patterns of alertness and performance and includes a vital need for sleep. Human requirements for sleep and a stable circadian clock can be, and often are, in direct opposition to the societal demand for continuous operations. Recently, patient safety has taken center stage in health care. The Institute of Medicine’s report “To Err Is Human: Building a Safer Health System,” revealed that medical errors contribute to many hospital deaths and serious adverse events. The response to this report was widespread and included the Quality Interagency Coordination Task Force’s response to the President of the United States, “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.” 2 This report listed more than 100 action items to be undertaken by federal agencies to improve quality and reduce medical errors. One action promised by the Agency for Healthcare Research and Quality was “the development and dissemination of evidence-based, best safety practices to provider organizations.” In addition to the multiple recommendations to improve patient safety, the report from the Agency for Healthcare Research and Quality included a review chapter on sleep, fatigue,# and medical errors.** There is evidence that the issue of fatigue in health care is coming to prominence on a national level. In April 2001, Public Citizen (a consumer and health advocacy group) and a consortium of interested parties petitioned the Occupational Safety and Health Administration to implement new regulations on resident work hours (table 1). The primary intent of the regulations is to provide more humane working conditions, which the petitioners declare will result in a better standard of care for all patients. Also, the Patient and Physician Safety and Protection Act of 2001, which would limit resident physician work hours, was introduced in Congress. Recently, the Accreditation Council on Graduate Medical Education, the accrediting organization for residency training programs in the United States, has approved common program requirements for resident duty and rest hours that will take effect in July 2003.†† This article is accompanied by an Editorial View. Please see: Lydic R: Fact and fantasy about sleep and anesthesiology. ANESTHESIOLOGY 2002; 97:1050–1.

Medication errors in anesthetic practice: a survey of 687 practitioners.

The objectives of this study were to determine: 1) if anesthesiologists had experienced a medication error and 2) to identify causal factors. The perceived value of a Canadian reporting agency for medication errors and improved standards for labels on drug ampoules was also investigated. A self-reporting survey was mailed to members of the Canadian Anesthesiologists' Society (n = 2,266). Respondents provided free-text descriptions of medication errors and answered fixed response questions. Surveys from 687 anesthesiologists (30% response rate) revealed that 85% of the participants had experienced at least one drug error or "near miss". Although most errors (1,038) were of minor consequence (98%), four deaths were reported. The commonest error involved the administration of muscle relaxants instead of a reversal agent. "Syringe swaps" (70.4%) and the misidentification of the label (46.8%) were common contributing factors. Anesthesiologists (97.9%) reported that they read the ampoule label "most of the time" although the label colour was an important secondary cue. Approximately half of the participants would report the error if a reporting program existed and 84% agreed that improved standards for drug labels would reduce the incidence of error. Most anesthesiologists experienced at least one drug error. The commonest error was a "syringe swap" that involved a muscle relaxant. Most errors were of minor consequence, however, serious morbidity and mortality resulted from clearly preventable events. These results support the development of improved standards for drug labels and the establishment of a Canadian reporting program for medication errors.

Attitudes and practices of New Zealand anaesthetists with regard to emergency drugs.

A postal survey of anaesthetists practising in New Zealand assessed practices with regard to the preparation of pre-drawn syringes of emergency drugs in theatre, and attitudes towards the drawing up of drugs by non-medically qualified assistants. Opinion and practice varied widely; a quarter of respondents routinely draw up such drugs and a third either never or very infrequently do so. The drugs most commonly drawn up in this way were suxamethonium, atropine, syntocinon, ephedrine and metaraminol. Providing anaesthesia single-handed, anaesthesia involving paediatric, obstetric or vascular cases, the use of major regional techniques and laryngeal mask anaesthesia were reported as factors which prompted a number of respondents to draw up one or more of these drugs. The majority (68.5%) had received no teaching on the issue and nearly all (83.5%) reported that there was no institutional policy in their workplace(s). "Syringe swap" or "wrong drug" errors related to such pre-drawn drugs were reported by 26.5%, while delay in drawing up a drug in an emergency was reported by 37%. Nearly all (98%) respondents believed that it was acceptable for an anaesthetic technician (or similar assistant) to draw up drugs in an emergency but only 14% approved of assistants drawing up drugs routinely. We conclude that there is no uniformity of opinion amongst New Zealand anaesthetists about which if any drugs should be pre-drawn for possible emergency use, and that few would endorse the drawing up of drugs by non-medically qualified assistants, except in emergency, or under other clearly delineated circumstances.

Adverse drug errors in anesthesia, and the impact of coloured syringe labels.

To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors. We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed. Errors were divided into four groups: syringe swap, ampoule swap, other 'wrong drug' errors, and wrong dose errors. The problems were graded into four levels, according to severity. A drug error was recorded in 63 cases (0.11%). There were 28 syringe swaps, and muscle relaxants were erroneously given in 15. There were nine ampoule swaps. There were eight 'other wrong drug' cases, and 18 cases where a wrong dose of the correct drug was given. Three of the drug errors were classified as serious, and 27 were of moderate severity. We found no differences between the two periods except for decreased number of ampoule swaps (P = 0.04). Drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps occurred most often between syringes of equal size, and were not eliminated by colour coding of labels. As muscle relaxant drugs are most commonly involved, and can cause lasting morbidity, special preventive measures should be taken for this group of drugs.

Anaesthesia and fatigue: an analysis of the first 10 years of the Australian Incident Monitoring Study 1987-1997.

The Australian Incident Monitoring Study (AIMS) database of the Australian Patient Safety Foundation (APSF) was reviewed from its inception in April 1987 to October 1997. A total of 5600 AIMS reports were lodged in that period. Reports in which fatigue was listed as a Factor Contributing to Incident were examined. This occurred in 152 reports, or 2.7% of all reports. Confidence interval analysis suggested that fatigue was associated with various concurrently reported factors. These included pharmacological incidents (especially syringe swaps) and time of day. Other factors significantly associated with fatigue reports were haste, distraction, inattention and failure to check equipment. Relieving anaesthetists and healthy patients were reported more often as factors minimizing incidents. Anaesthetists reporting fatigue more often reported incidents during induction. These data suggest that fatigue alleviation strategies and equipment checking routines, improved workplace design (including drug ampoule and syringe labelling protocols) and regulation of working hours will facilitate minimization of fatigue-related incidents. Definitive prospective studies might be most usefully targeted at these and related interventions.

The Australian Incident Monitoring Study. Patient awareness during anaesthesia: an analysis of 2000 incident reports.

Amongst the first 2000 incidents reported to the Australian Incident Monitoring Study were 16 cases in which patient recall of perioperative events was consistent with awareness. Awareness that occurred in 3 of 10 cases during anaesthesia was attributed to low concentrations of volatile anaesthetic agent; the conduct of anaesthesia appeared to be unremarkable in the other 7. The remaining 6 cases involved the inadvertent paralysis of patients prior to induction of anaesthesia, most commonly by "syringe swap" when suxamethonium was given instead of fentanyl. Some of these patients were significantly distressed. These preliminary findings suggest that incident monitoring should be useful in the study of awareness associated with anaesthesia and the development of strategies to prevent it.

Preventable anesthesia mishaps: a study of human factors.

A modified critical-incident analysis technique was used in a retrospective examination of the characteristics of human error and equipment failure in anesthetic practice. The objective was to uncover patterns of frequently occurring incidents that are in need of careful prospective investigation. Forty-seven interviews were conducted with staff and resident anesthesiologists at one urban teaching institution, and descriptions of 359 preventable incidents were obtained. Twenty-three categories of details from these descriptions were subjected to computer-aided analysis for trends and patterns. Most of the preventable incidents involved human error (82 per cent), with breathing-circuit disconnections, inadvertent changes in gas flow, and drug-syringe errors being frequent problems. Overt equipment failures constituted only 14 per cent of the total number of preventable incidents, but equipment design was indictable in many categories of human error, as were inadequate experience and insufficient familiarity with equipment or with the specific surgical procedure. Other factors frequently associated with incidents were inadequate communication among personnel, haste or lack of precaution, and distraction. Results from multi-hospital studies based on the methodology developed could be used for more objective determination of priorities and planning of specific investments for decreasing the risk associated with anesthesia.