Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database.

Eight hundred and ninety-six incidents relating to drug error were reported to the Australian Incident Monitoring Study. Syringe and drug preparation errors accounted for 452 (50.4%) incidents, including 169 (18.9%) involving syringe swaps where the drug was correctly labelled but given in error, and 187 (20.8%) due to selection of the wrong ampoule or drug labelling errors. The drugs most commonly involved were neuromuscular blocking agents, followed by opioids. Equipment misuse or malfunction accounted for a further 234 (26.1%) incidents; incorrect route of administration 126 (14.1%) incidents; and communication error 35 (3.9%) incidents. The outcomes of these events included minor morbidity in 105 (11.7%), major morbidity in 42 (4.7%), death in three (0.3%) and awareness under anaesthesia in 40 (4.4%) incidents. Contributing factors included inattention, haste, drug labelling error, communication failure and fatigue. Factors minimising the events were prior experience and training, rechecking equipment and monitors capable of detecting the incident. The information gained suggests areas where improved guidelines are required to reduce the incidence of drug error. Further research is required into the effectiveness of preventive strategies.

Awareness during general anaesthesia: a review of 81 cases from the Anaesthetic Incident Monitoring Study.

Because of recent studies suggesting that awareness is still a major issue in anaesthetic practice, we reviewed 8372 incidents reported to the Anaesthetic Incident Monitoring Study. There were 81 cases in which peri-operative recall was consistent with awareness. There were 50 cases of definite awareness and 31 cases with a high probability of awareness. In 13 of the 81 incidents, the patients appeared to receive adequate doses of anaesthetic drugs. Where the cause could be determined, awareness was mainly due to drug error resulting in inadvertent paralysis of an awake patient (n = 32) and failure of delivery of volatile anaesthetic (n = 16). Less common causes included prolonged attempts at intubation of the trachea (n = 5), deliberate withdrawal of volatile anaesthetic (n = 4) or muscle relaxant apnoea with inadequate administration of hypnotic (n = 3). An objective central nervous system depth of anaesthesia monitor may have prevented 42 of these incidents and an improved drug administration system may have prevented 32. On the basis of these reports, we have developed guidelines that may have prevented the majority of these incidents.