• Ann Fr Anesth Reanim · Jan 2012

    [Medication errors in anaesthesia: a review of reports from the French Health Products Agency].

    • V Piriou, D Durand, A Arnoux, A Rivière, and A Castot-Villepelet.
    • Service de l'évaluation et de la surveillance du risque et de l'information sur le médicament, direction de l'évaluation des médicaments et des produits biologiques, agence française de sécurité sanitaire des produits de santé, Saint-Denis, France.
    • Ann Fr Anesth Reanim. 2012 Jan 1;31(1):6-14.

    BackgroundThe purpose of this study was to assess medication errors and risks of medication errors during anaesthetic practice reported at the French Health Products Agency (Afssaps) from 2005 to 2010.Study DesignDescriptive study.MethodsThe data are issued of "Medication errors and risks of medication errors" file which group together all cases received by the Medication Errors Unit at Afssaps since 2005.ResultsA total of 263 cases were observed by the Medication Errors Unit at Afssaps. Among them, 159 cases were risks of medication errors, 76 cases were patent medication errors and 28 were near misses. Among the 76 cases of patent medication errors, out of which 47 cases were appreciated with adverse reaction and 35 cases were classified as serious. Adverse events were classified as haemodynamic, respiratory and neurologic events. Most of the errors occurred during administration (65%), followed by dispensing errors (14%), storage errors (15%) or preparation errors (4%). Sixty-nine percent of cases of wrong drug errors were found, followed by 26% of errors of strength, 3% of incorrect route of administration errors and 2% of patient errors. In most of cases, similarity in packaging was underlined (n=83).ConclusionThis study showed that the majority of medication errors and risks of medication errors during anaesthetic practice, underline similarity in packaging. Results highlighted the importance of vial labeling presentation (readability and mention understanding) in anaesthetic practice.Copyright © 2011. Published by Elsevier SAS.

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