Drug administration errors among anesthesiologists: The burden in India - A questionnaire-based survey

Abstract

Background and aims: Safe medication is an important part of anesthesia practice. Even though anesthesia practice has become safer with various patient safety initiatives, it is not completely secure from errors which can sometimes lead to devastating complications. Multiple reports on medication errors have been published; yet, there exists a lacuna regarding the quantum of these events occurring in our country or the preventive measures taken. Hence, we conducted a survey to study the occurrence of medication errors, incident reporting, and preventive measures taken by anesthesiologists in our country.

Material and methods: A self-reporting survey questionnaire (24 questions, 4 parts) was mailed to 9000 anesthesiologists registered in Indian Society of Anaesthesiologists via Survey Monkey Website.

Results: A total of 978 completed surveys were returned for analysis (response rate = 9.2%). More than two-thirds (75.6%, n = 740) had experienced drug administration error and 7.7% (57) of respondents faced major morbidity and complications. Haste/Hurry (23.4%) was identified as the most common contributor to medication errors in the operation theater. Loading and double-checking of drugs before administration by concerned anesthesiologist were identified as safety measures to reduce drug errors.

Conclusion: Majority of our respondents have experienced drug administration error at some point in their career. A small yet important proportion of these errors have caused morbidity/mortality to patients. The critical incident reporting system should be established for regular audits, an effective root cause analysis of critical events, and to propose measures to prevent the same in future.

Keywords: Anesthesiology; burden; drug administration; medication error.

Figure 1

Factors which play major roles in causing errors in drug administration

Figure 2

Respondents opinion on strategies which can reduce drug errors. A = Color coding of syringes, B = reducing daytime working hours of anesthesiologist, C = reducing the number of night shifts, D = loading and administration of drugs by the concerned anesthesiologist, E = double-checking of medications before administration, F = use of prefilled syringes in operation theater

Figure 3

Color labeling of syringe pistol containing high alert drugs