Drug errors: consequences, mechanisms, and avoidance

Medication errors are common throughout healthcare and result in significant human and financial cost. Prospective studies suggest that the error rate in anaesthesia is around one error in every 133 anaesthetics. There are several categories of medication error ranging from slips and lapses to fixation errors and deliberate violations. Violations may be more likely in organizations with a tendency to blame front-line workers, a tendency to deny the existence of latent conditions, and a blinkered pursuit of productivity indicators. In these organizations, borderline-tolerated conditions of use may occur which blur the distinction between safe and unsafe practice. Latent conditions will also make the error at the 'sharp end' more likely to result in actual patient harm. Several complementary strategies are proposed which may result in fewer medication errors. At the organizational level, developing a safety culture and promoting robust error reporting systems is key. The individual anaesthetist can play a part in this, setting an example to other members of the team in vigilance for errors, creating a safety climate with psychological safety, and reporting and learning from errors.