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

P C Gordon1, R L Llewellyn, M F M James

  • 1Department of Anaesthesia, Groote Schuur Hospital and University of Cape Town. gordon@cormack.uct.ac.za

South African Medical Journal = Suid-Afrikaanse Tydskrif Vir Geneeskunde
|August 16, 2006
PubMed
Summary

Most South African anaesthetists inadvertently administer the wrong drug, often involving muscle relaxants due to syringe swaps. While most errors are minor, some lead to severe harm or death.

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Area of Science:

  • Anesthesiology
  • Patient Safety
  • Medication Errors

Background:

  • Wrong drug administration is a significant concern in anesthesia.
  • Understanding contributing factors is crucial for improving patient safety.

Purpose of the Study:

  • To investigate the incidence, nature, and contributing factors of wrong drug administrations by South African anaesthetists.
  • To compare incidence rates with international data.

Main Methods:

  • A confidential, self-reporting survey was distributed to 720 anaesthetists.
  • A 18.5% response rate was achieved, with 133 questionnaires analyzed.

Main Results:

  • 94% of respondents admitted to inadvertent wrong drug administration.

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  • The most common error was 'syringe swaps' (40%), frequently involving muscle relaxants (nearly 50%).
  • Significant morbidity, including 5 deaths and 3 cardiac arrests, was reported.

    • Conclusions:

    • The incidence of wrong drug errors in South Africa is comparable to other regions.
    • Improving ampoule and syringe labeling, and establishing a national reporting system are recommended.
    • Addressing factors like fatigue and distractions is essential for reducing medication errors.