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Drug administration errors: a prospective survey from three South African teaching hospitals
R L Llewellyn1, P C Gordon, D Wheatcroft
1Department of Anaesthesia, University of Cape Town, Cape Town, Republic of South Africa.
Anaesthesia and Intensive Care
|January 23, 2009
Summary
Drug administration errors by anaesthetists are common in South African hospitals, occurring at a rate of 1:274. Most errors involved drug substitution or misidentification, highlighting ongoing patient safety risks.
Area of Science:
- Medical Science
- Anesthesiology
- Patient Safety
Background:
- Drug administration errors pose a significant risk in healthcare settings.
- Previous studies suggest a need for improved error reporting and prevention strategies in anesthesiology.
Purpose of the Study:
- To determine the incidence of drug administration errors and near-misses by anaesthetists in South African tertiary hospitals.
- To identify common types and causes of these errors to inform patient safety initiatives.
Main Methods:
- A prospective, anonymous study involving anaesthetists across three South African hospitals over six months.
- Data collection through study forms detailing every anaesthetic, including any errors or near-misses.
- Analysis of 30,412 administered anaesthetics to calculate error incidence rates.
Main Results:
- An overall error and near-miss incidence of 1:274 anaesthetics was reported (53% response rate).
- Most frequent errors included drug substitution and misidentification (36.9% due to similar-looking ampoules), and syringe identification errors (21.3%).
- Errors occurred most often during the maintenance phase of anaesthesia, unaffected by anaesthetist experience or emergency surgery.
Conclusions:
- Drug administration errors remain a prevalent issue in South African anaesthesiology despite increased awareness.
- Similar-looking drug ampoules and syringe misidentification are key contributors to errors.
- Failure to implement evidence-based solutions will continue to jeopardize patient safety in these settings.
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