Medication Errors During Anaesthesia: Data from Australia & New Zealand

Medication errors have featured strongly in many reports of critical incidents, and were the second most common category of incidents in the first 4000 cases reported to webAIRS (web-based Anaesthetic Incident Reporting System) [1]. 462 of the reported incidents involved medication errors of various types (table 1).

Of these, 58.9% resulted in at least some harm (fig 1):

Incorrect dose and substitution errors were most likely to result in patient harm. Incorrect doses were predominantly overdoses and most often involved:

  • Opioids;
  • Sympathomimetics;
  • Local anaesthetics; and
  • Insulin

  • 36% of the opioid dose errors involved remifentanil infused in a wrong concentration or via an incorrectly programmed syringe pump.
  • Ten- fold overdoses were reported for both morphine and insulin.

75% of substitution errors involved the intravenous (IV) route of administration but substitutions also occurred with others:

  • IV infusions;
  • Epidural infusions;
  • Subcutaneous;
  • Inhalational;
  • Spinal; and
  • Ophthalmic.

  • The commonest IV substitution errors involved the administration a non-depolarising neuromuscular blocking agent instead of midazolam (pre-induction), with all but one rated as causing moderate or severe harm.
  • Sympathomimetics, opioids, an antibiotic and an analgesic were substituted for an intended LA in epidurals.

Common contributing factors included:

  • Look-alike medications;
  • Storage of medications in the incorrect compartment or next to look-alike medications;
  • Haste;
  • Having multiple anaesthetists involved in the same anaesthetic;
  • Omitting to double check the medication; and
  • Distraction.

Prominent amongst the other reported issues were:

  • Administration of LA agents IV or intra-arterially;
  • Extravasation of IV medications into a patient’s tissues;
  • Failed delivery of IV infusions due to failed connection of the line and cannula;
  • Failure to start an intended volatile agent;
  • Administration of medications for which there was a known history of allergy.

89% of incidents were regarded (by the submitting anaesthetist) as being preventable. Contributory factors identified in the reports of medication errors included:

  • Failure to check medications;
  • Inattention,
  • Distraction;
  • Haste or pressure to proceed;
  • Fatigue;
  • The presence of multiple staff; and
  • Poor communication.

There is an undisputed professional and legal obligation for every anaesthetist to check each medication administered, including dose and route. However, there are also challenges in anaesthesia practice in relation to multiple simultaneous demands

  • Ongoing assessment of dynamic clinical situations;
  • Parallel processing in relation to current, previous and impending cases;
  • Interactions with operators and nursing staff; and
  • Teaching.

The authors strongly argue for the need and value of repeated checking, whether by the individual practitioner, with a second practitioner (another anaesthetist or a colleague from another discipline), or with a device such as a barcode reader (see article by Richard Skelly). They particularly state that in situations of low-volume, high-risk routes of administration (notably spinal and epidural), double checking should be mandatory. They also advocate for the implementation of a variety of other tools including:

  • Prefilled syringes;
  • Improved training in teamwork and communication, alongside promoting the importance of these skills within departments and institutions;
  • Departmental policies and checklists for matters such as
  • Flushing residual medication from IV lines;
  • STOP before you block;
  • Not having IV cannulae concealed by surgical drapes where possible, and double checking to ensure the patency of all connectors.

The authors conclude “The incident reports summarised in this paper suggest that medication error in anaesthesia is an ongoing problem which continues to result in avoidable patient harm. The wide variation in the nature of the errors and contributing factors underlines the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare”.

References: [1] Kim et al. Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS. Anaesthesia and Intensive Care 2021. doi:10.1177/0310057X211027578.