[Medication errors in anesthesia: a Moroccan university hospitals survey]

Medication errors are a major public health problem because of their morbidity and financial costs. In anesthesia, few articles publications, mostly retrospective, have assessed its incidence and outcomes. By our prospective study, we intend to identify and describe the drug errors in anesthesia in four university hospitals in Morocco.

After approval of our ethics committee, a prospective study was conducted in nine hospitals affiliated to four university hospitals (Rabat, Casablanca, Fes and Marrakech) from October 2009 to June 2010. Data collection was carried out by an anesthesiologist at each hospital who was designated by the investigator. Informations were based on practitioner's statements. Medication errors were divided into distinct categories: substitution errors, omission errors, errors of the way of administration, dosage and dilution errors. The consequences were classified into four levels according to their severity.

During the study period, 9199 anesthetic procedures were reported (mean response of 36%). General anesthesia was performed in 75% of patients. Sixteen cases of drug errors were reported (an incidence of 1/575 with 1/405 in a pediatric setting). The drugs involved were dominated by hypnotics (six cases/16) and morphine (four cases/16). Medication errors were mainly due to labeling mistakes (seven cases/16) and to attention deficit due to fatigue and stress (seven other cases) leading to substitution error in most of cases (10 cases/16. Errors were mainly made by the less experienced practitioners (14 cases/16). They occurred during the induction phase (seven cases/16) as well as during the interview process (nine cases/16), and also during emergent surgeries (seven errors/16) as well as during elective ones (nine errors/16). No errors caused death. Pulmonary edema (recognized as a grade III severity incident) was secondary to inappropriate administration of adrenaline.

Our study helped us to set recommendations, which are approved by the Moroccan pharmacovigilance center, and in accordance with the international committees to prevent the occurrence of medication errors in our daily anesthetic practice.