Drug administration errors by South African anaesthetists - a survey

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dc.contributor.authorGordon, P C
dc.contributor.authorLlewellyn, R L
dc.contributor.authorJames, M F M
dc.date.accessioned2017-05-24T13:39:28Z
dc.date.available2017-05-24T13:39:28Z
dc.date.issued2006
dc.date.updated2016-01-08T10:05:15Z
dc.description.abstractObjectives. To investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists. Design. A confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists. Results. A total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard. Conclusions. Most anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a ‘syringe swap’ involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents.
dc.identifierhttp://dx.doi.org/10.7196/SAMJ.1167
dc.identifier.apacitationGordon, P. C., Llewellyn, R. L., & James, M. F. M. (2006). Drug administration errors by South African anaesthetists - a survey. <i>South African Medical Journal</i>, http://hdl.handle.net/11427/24407en_ZA
dc.identifier.chicagocitationGordon, P C, R L Llewellyn, and M F M James "Drug administration errors by South African anaesthetists - a survey." <i>South African Medical Journal</i> (2006) http://hdl.handle.net/11427/24407en_ZA
dc.identifier.citationGordon, P., Llewellyn, R., & James, M. (2006). Drug admininstration errors by South African anaesthetists - a survey. South African Medical Journal, 96(7), 630.
dc.identifier.ris TY - Journal Article AU - Gordon, P C AU - Llewellyn, R L AU - James, M F M AB - Objectives. To investigate the incidence, nature of and factors contributing towards wrong drug administrations by South African anaesthetists. Design. A confidential, self-reporting survey was sent out to the 720 anaesthetists on the database of the South African Society of Anaesthesiologists. Results. A total of 133 questionnaires were returned for analysis (18.5% response rate). Of the respondents, 125 (94%) admitted to having inadvertently administered a wrong drug. Thirty respondents (22.6%) said they had made errors on at least four occasions. A total of 303 specific wrong drug administrations were described. Nearly 50% involved muscle relaxants. A further 43 incidents (14%) involved the erroneous administration of vasoactive drugs. Five deaths and 3 nonfatal cardiac arrests were reported. In 9.9% of incidents the anaesthetic time was prolonged by more than 30 minutes. Contributory causes identified included syringe swaps (40%), misidentification of drugs (27.1%), fatigue (14.1%), distractions (4.7%), and mislabelling of syringes (4.7%). Only 19% of respondents regularly use colour-coded syringe labels complying with the national standard. Conclusions. Most anaesthetists experienced at least one drug error. The incidence of wrong drug administrations by South African anaesthetists appears to be similar to that in Australasia and Canada. The commonest error was a ‘syringe swap’ involving muscle relaxants. Most drug errors are inconsequential. An important minority of incidents result in severe morbidity or death. The study supports efforts to improve ampoule labelling, to encourage the use of syringe labels based on the international colour code and to develop a national reporting system for such incidents. DA - 2006 DB - OpenUCT DP - University of Cape Town J1 - South African Medical Journal LK - https://open.uct.ac.za PB - University of Cape Town PY - 2006 T1 - Drug administration errors by South African anaesthetists - a survey TI - Drug administration errors by South African anaesthetists - a survey UR - http://hdl.handle.net/11427/24407 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/24407
dc.identifier.vancouvercitationGordon PC, Llewellyn RL, James MFM. Drug administration errors by South African anaesthetists - a survey. South African Medical Journal. 2006; http://hdl.handle.net/11427/24407.en_ZA
dc.language.isoeng
dc.publisher.departmentDepartment of Anaesthesiaen_ZA
dc.publisher.facultyFaculty of Health Sciencesen_ZA
dc.publisher.institutionUniversity of Cape Town
dc.sourceSouth African Medical Journal
dc.source.urihttp://www.samj.org.za/index.php/samj
dc.subject.otherSouth Africa
dc.subject.otherAnaesthetists
dc.subject.otherDrug administration
dc.subject.otherErrors
dc.subject.otherIncidence
dc.subject.otherContributing factors
dc.titleDrug administration errors by South African anaesthetists - a survey
dc.typeJournal Articleen_ZA
uct.type.filetypeText
uct.type.filetypeImage
uct.type.publicationResearchen_ZA
uct.type.resourceArticleen_ZA
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