Drug Errors Flashcards
(6 cards)
What pieces of information from a patient’s preoperative assessment could help to prevent intravenous drug administration errors
Drug History
Allergy Status
Past Medical History and Anaesthetic History
patient’s height and weight
What behavioural factors might contribute to anaesthetic intravenous drug administration errors?
Lack of Knowledge:
Unfamiliarity with a particular drug, for example, it’s routes of administration, dilution etc.
Human Cognition:
Human memory - this can not be relied upon to remember all infusion mix-ups, dose variations etc.
Difficulty with complex calculations, for example, paediatrics or infusions, or even worse, paediatric infusions!!
Distraction:
Needing to address other tasks whilst also drawing up drugs, prescribing drugs, calculating doses, and giving drugs.
Handling more than one medication at a time
Stress / Fatigue / Excessive physical demands:
Tiredness e.g., as a result of night work
Non-work emotional issues causing reduced work performance
Excessive workload, for example,e a high turnover list
Lack of teamwork:
Lack of double-checking of drugs
Failure to feel able to express a lack of knowledge about a particular drug and its administration
Failure to implement a “no blame culture” lack of encouragement of reporting and learning from errors
Poor communication, poor handover e.g. failure of one member of a team to give explicit instructions to another about the administration of a particular drug or whether a drug has already been given.
What environmental factors might contribute to anaesthetic intravenous drug administration errors
Cluttered workspace
Low light levels
Drugs with similar packaging, changes in packaging without notice, unclear or too small labelling, and lettering size
Multiple drugs drawn up, similar sized syringes, lack of labelling
Distractions or noisey environment
Non IV lines for example ART Lines, or epidural catheters, being used in the same operation, and failure to adequately identify or label these additional lines.
Drugs intended for IV use are stored together with local anaesthetic drugs
Multiple concentrations of the same drug available for use
Drugs in excessive or dangerous concentrations (which require dilution) available in anaesthetic drug cupboard or trolley.
What organisational strategies might minimise IV drug administration errors?
Processes:
Standardisation of drug cross-checking and handover etc.
Standardisation of infusions, dilutions etc. and reprogramming of pumps
Availability of reference databases for doses, dilutants and calculations
Standardisation of trays, for example keeping emergency drugs, patient specific drugs and non IV drugs in separate trays
Regulations regarding what is drawn up, by whom and at what stage in the care of a patient
Avoidance of distraction during drug preparation
Checklist to ensure prescription chart is checked before administration of drugs by the anaesthetist to avoid double dosing or omitting doses
Investigation the possibility of pre mixed infusions
Flushing all lines as standard before leaving theatre and recovery
bar-code scanning identification of drugs before use
Physical environment:
Availability of red barrelled syringes for use with neuromuscular blocking drugs
Standardising the layout and content of anaesthetic charts
The use of NR Fit equipment to reduce the risk of inadvertent intravenous injection of local anaesthetic drugs
Ensure intrathecal and epidural drugs are stored separately from IV drugs
Removal of non essential, rarely used drugs from the drug cupboard / trolley which have a high injury risk if inadvertently given (sadly no examples provided)
Ensuring label availability at all times
Process for dealing with unused ampoules to prevent them from being returned to incorrect box (for example second person check or discard altogether)
Ensure adequate lighting levels
Sourcing of products with clear labelling, sufficiently large lettering etc. where possible
Team Working:
Simulation sessions to highlight risks to all team members
Unusual drugs to be dealt with in team briefing
Encouragement of working environment where any team member feels able to voice their concerns
Inclusion of a pharmacist in the team to notify team members about changes in product appearance and education about new drugs being added to drug cupboards / trolleys
What are the important aspects of responding to an anaesthesia related intravenous drug administration error after the episode of care has been completed
Open incident reporting of errors and near misses with no blame culture, with fair root cause analysis and feedback to the individual involved.
Discussion at morbidity and mortality meetings for education of all team members about pitfalls that might lead to an error
Regular audit of collective reports and quality improvement interventions where specific failings have been identified
Communication with patient following a duty of candour statutory duty
Management of staff involved in error in accordance with the NHS England “A Just CultureGuide”
List potential never events pertinent to the administration of intravenous medications during anaesthetic care
Mis-selection of a strong potassium containing solution
Wrong route administration
Overdose of insulin due to abbreviations or incorrect device
Mis-selection of high strength midazolam during conscious sedation
