Drug related critical incidents

Anaesthesia. 2005 Jan;60(1):48-52. doi: 10.1111/j.1365-2044.2004.04014.x.

Abstract

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.

MeSH terms

  • Anesthesia / adverse effects*
  • Anesthesia / standards
  • Developing Countries
  • Drug-Related Side Effects and Adverse Reactions
  • Hospitals, Teaching / statistics & numerical data
  • Humans
  • Medication Errors / prevention & control
  • Medication Errors / statistics & numerical data*
  • Medication Errors / trends
  • Neuromuscular Blocking Agents / adverse effects
  • Pakistan
  • Safety Management / methods

Substances

  • Neuromuscular Blocking Agents